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NUR 3020 exams > skin disorder > Flashcards

skin disorder Flashcards

1
Q

what makes up the integumentary system (3)

A
  • skin
  • hair
  • nails
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2
Q

skin

A

plays a major role in protection by acting like the first line of defense, as well as helps regulate body temperature and maintains fluid and electrolyte balance

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3
Q

hair

A

differs in type and function in various body areas

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4
Q

nails

A

useful for grasping and scraping and have cosmetic value

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5
Q

eccrine sweat glands

A

allow dissipation of heat through evaporation of sweat secreted onto the skin surface

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6
Q

changes in epidermis r/t aging (9)

A

1) decreased epidermal thickness -> skin transparency and fragility
2) decreased cell division -> delayed wound healing
3) decreased epidermal mitotic homeostasis -> skin hyperplasia, skin cancers (sun exposed areas)
4) increased epidermal permeability -> increased risk for irritation
5) decreased immune system cells -> decreased skin inflammatory response
6) decreased melanocyte activity -> increased risk for sunburn
7) hyperplasia of melanocyte activity -> changes in pigmentation
8) decreased vit. D production -> increased risk for osteomalacia
9) flattening of dermal/epidermal junction -> increased risk for shearing forces, resulting in blisters, purpura, skin tears and pressure related problems

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7
Q

nursing interventions for epidermis (9)

A

1) handle patients carefully to reduce skin friction and shear, assess for excessive dryness or moisture, avoid taping the skin
2) avoid skin trauma, protect open areas
3) assess non-sun exposed areas for baseline skin features, assess exposed skin areas for sun induced changes
4) teach pt. how to avoid exposure to skin irritants
5) do NOT rely on degree of redness and swelling to correlate w/ severity of skin injury or localized infection
6) teach patients to wear heats, sunscreen, and protective clothing, teach pt. to avoid sun exposure from 10am-4pm
7) teach pt. to keep track of pigmented lesions, teach them what changes should be evaluated for malignancy
8) urge pt. to take a multiple vitamin or calcium supplement from vit. D
9) avoid pulling or dragging pt., assist pt. confined to bed or chairs to change least Q2H, avoid or use care when removing adhesive wound dressings

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8
Q

changes in the dermis r/t aging (6)

A

1) decreased dermal BF -> increase susceptibility to dry skin
2) decreased vasomotor responsiveness -> increased risk for heat stroke and hypothermia
3) decreased dermal thickness -> paper thin, transparent skin w/ increased susceptibility to trauma
4) degeneration of elastic fibers -> decreased tone and elasticity
5) benign proliferation of capillaries -> cherry hemangiomas
6) reduced number and function of nerve endings -> reduced sensory perception

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9
Q

nursing interventions for dermis (6)

A

1) teach pt. to apply moisturizers when the skin is still moist and to avoid agents that produce dryness
2) teach pt. to dress for the environmental temperatures
3) handle patients gently, and avoid the use of tape or tight dressings, use lift sheets when positioning patients
4) check skin turgor on the forehead/chest
5) teach pt. that these are benign (cherry hemangiomas)
6) tell pt. to use bath thermometer and lower water heart temp. to prevent scalds

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10
Q

changes in subQ layer r/t aging (what, nursing intervention (2))

A

1) thinning subcutaneous layer -> increased risk of hypothermia and increased risk for pressure injury
- NI: teach pt. to dress warmly in cold weather, assist patients to confined to bed or chairs to change positions at least every 2 hours

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11
Q

skin inspection (5)

A

observe and document feaures
- obvious changes in color and vascularity
- presence or absence of moisture
- edema
- skin lesions
- skin integrity (intact, wounds?)

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12
Q

skin assessment techniques for patients w/ darker skin (5)

A
  • pallor: can be detected in people w/ dark skin by first inspecting the mucous membranes for an ash-gray color
  • cyanosis: can be detected in the lips and tongue appearing gray and the palms, soles, conjunctivae, and nail beds have a bluish tinge
  • inflammation: dark skinned patients appears as excessive warmth and changes in skin consistency or texture (palpation)
  • jaundice: best assessed bu inspecting the oral mucosa, esp. hard palate, for yellow discoloration
  • ecchymosis: appear darker than normal skin, they may be tender and easily palpable
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13
Q

lesions in skin types (2)

A

1) primary lesions: initial reaction to a problem that alters skin components
2) secondary lesions: changes in the appearance of the primary lesion; these changes occur with progression of an underlying disease or in response to a topical or systemic therapeutic intervention

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14
Q

annular

A

circular

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15
Q

circumscribed

A

well defined w/ sharp borders

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16
Q

clustered

A

several lesions grouped together

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17
Q

coalesced

A

lesions that merge w/ one another and appear confluent

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18
Q

diffuse

A

widespread, involving most of the body w/ intervening areas of normal skin
- generalized

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19
Q

linear

A

occurring in a straight line

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20
Q

serpiginous

A

with wavy borders, resembling a snake

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21
Q

universal

A

all areas of the body invovled, with no areas of normal appearing skin

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22
Q

skin palpation (what, 4)

A

use palpation to gather additional information about skin lesions, moisture, temperature, texture, and turgor
- palpation: confirms lesion size and whether they are flat or slightly raised
- consistency of larger lesions: can vary from soft and pliable to firm and solid
- subtle changes: diff. between fine macular rash and a papular rash are best determined by palpating with your eyes closed
- ask the patient whether skin palpation causes pain or tenderness

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23
Q

skin diagnostic lab/test (3)

A

lab:
- cultures

test:
- skin biopsy (fungal infections)
- wood’s light examination: lesions increased in whiteness
- diascopy: determine erythema d/t superficial vessel or hemorrhage

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24
Q

pressure ulcers (what, tissue compression, complications)

A
  • loss of tissue integrity caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period
  • tissue compression: from pressure restricts BF to the skin, resulting in reduced tissue perfusion and oxygenation, and eventually lead to call death
  • complications: sepsis, kid failure, infectious arthritis, osteomylestis
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25
Q

PU: assess for any contributing factors (8)

A
  • prolonged BR
  • immobility
  • incontinence
  • DM
  • inadequate nutrition or hydration
  • decreased sensory perception or cognitive problems
  • peripheral vascular disease
  • friction and sheering forces

Whole body inspection!

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26
Q

incontinence associated dermatitis (IAD) (3)

A
  • skin damage associated with exposure to urine or stool
  • type or irritant contact dermatitis
  • once IAD occurs, there is a high risk for pressure ulcer development as well as increased risk of infection and morbidity
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27
Q

stage 1 PU (2, observe for (4))

A

1) skin is intact, red and DOES NOT BLANCH
2) for patients with darker skin that does no blanch
3) observe for changes compared w/ an adjacent or opposite area for:
- skin color darker or lighter than the comparison area
- skin temperature (warmth or coolness)
- tissue consistency (firm or boggy)
- sensation (pain, itching)

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28
Q

stage 2 PU (3)

A

1) partial thickness skin loss of the epidermis or dermis and skin is NOT INTACT
2) superficial, characterized as: abrasion, blister (open/fluid filled), shallow crater
3) bruising NOT PRESENT

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29
Q

stage 3 PU (3)

A

1) full thickness and damage extends down to but not through the underlying fascia: bone, tendon, and muscle NOT exposed
2) subcutaneous tissue may be damaged or necrotic
3) undermining and tunneling may or may NOT be present

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30
Q

stage 4 PU (3)

A

1) full thickness with exposed or palpable muscle, tendon, or bone
2) undermining, tunneling
3) slough and eschar present on at least part of the wound

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31
Q

deep tissue injury (3)

A

1) intact skin area appears PURPLE or MAROON
2) blood filled blisters may be present
3) firm, boggy, mushy, warmer, or cooler than the surrounding tissue before the color change occurred

32
Q

unstageable pressure ulcer

A

1) full thickness and the base is completely covered with slough or eschar, obscuring the true depth of the wound

33
Q

PU assessment (4)

A

1) location, size, color, extend of tissue involvement, cell types in wound base and margin, exudate, condition of surrounding tissue, tunneling, undermining, and presence of foreign bodies
2) document initial assessment to serve as a starting point for determining the intervention plan and its effectiveness
3) assess the wound at each dressing change, comparing the existing wound features with those documented previously to determine the current state of healing or deterioration
4) assess for signs of healing:
- beneath dead tissue, granulation tissue appears
- early granulation: pale pink, progressing to a beefy red color as it grows and fills the wound
- palpate the wound to determine the granulation texture
- healthy granulation tissue is MOIST and slightly spongy texture

TIP: want to keep moist as it’s healing

34
Q

PU nurse interventions for pressure relieving and pressure reducing techniques (14)

A
  • assist w/ major position changes Q2H bed, Q1H chair
  • pad contact surfaces w/ foam, silicon gel, air pads, or other pressure relieving pads
  • DO NOT keep HOB elevated above 30 degrees (prevent shearing)
  • use lift sheet to move a patient in bed, avoid dragging or sliding him or her
  • do NOT position directly on trochanter
  • place pillows or foam wedges between 2 bony surfaces
  • keep patient’s skin directly off plastic surfaces
  • help patient to maintain adequate intake of protein and calories and fluid intake of 2-3L/day
  • perform daily inspection of patient’s entire skin and document all sores/sign of infection
  • moisturize daily on dry skin, apply when skin is damp
  • keep moisture from prolonged contact w/ skin (keep areas dry where 2 skin surfaces touch, place absorbent pads under areas where perspiration collects, use moisture barriers on skin areas where wound drainage or incontinence occurs)
  • clean skin asap post soiling and at routine intervals
  • mild, heavily fatted soap or gentle commercial cleanser for incontinence w/ tepid rather than hot water
  • minimum scrubbing force necessary to remove soil and gently pat dry
35
Q

3 types of wound dressings for PU (3, name types)

A

1) passive: have only a protective function and maintain a moist environment for natural healing, they just cover that area and may remain in place for several days
- types: duoderm, tegaderm

2) interactive: capable of absorbing wound exudate while maintaining a moist environment in the area of the wound and allowing the surrounding skin to remain dry
- types: hydrocolloids, alginates, hydrogels

3) active: improve the healing process and decrease healing time
- types: skin grafts, biologic skin substitutes

36
Q

pressure ulcer surgical mgmt (3)

A
  • pressure ulcer includes removal of necrotic tissue and skin grafting or use of muscle flaps to close wounds that do not heal by re-epithelialization and contraction
  • those w/ poor blood flow are unlikely to have successful graft take and heal
  • procedures are very similar to the surgical mgmt of burn wounds
37
Q

negative pressure wound therapy (4)

A
  • can reduce or even close chronic ulcers by removing fluids or infectious materials from the wound and enhancing granulation
  • technique requires that a suction tube be covered by a special sponge and sealed in place
  • foam dressing is changed every 48-72 hours (3 times weekly), continuous low level negative pressure is applied through the suction tube
  • duration of the treatment is determined by the wound’s response
38
Q

impetigo (B/V/F, 4)

A
  • bacterial
  • characterized by: red macules that become thin-walled vesicles that rupture and become covered with honey-yellow crust (KEY)
  • formation of bullae (large fluid filled blisters) from original vesicles, then the bullae rupture leaving the red raw areas
  • exposed areas of the body, face, hands, neck, and extremities are most frequently involved
  • contagious and may spread to over parts of the body or to other people

EXTRA:
- hand hygiene, daily bathing, avoid contact with others, wash lesion with soap solution and apply abx (doxy, amoxicillin, MRSA Bactrim, clindomycin)
- if widespread: systemic infection (FEVER)

39
Q

folliculitis (B/V/F, 5)

A
  • bacterial
  • isolated erythematous pustules occur singly or in groups; hairs grow from cetners of many of the lesions
  • occasional papules are present
  • little not no associated discomfort
  • no residual scarring
  • areas of hair-bearing skin, especially areas of shaving, thighs, buttocks, and axillae are affected
40
Q

furuncle (boil) (B/V/F, 4)

A
  • bacterial
  • small, tender, erythematous nodules become pus filled
  • lesions may be single or multiple and also recurrent
  • may progress and involve the skin and subcutaneous fatty tissue, causing tenderness, pain, and cellulitis
  • occasional scarring results

extra:
- educate on no rupturing
- staphylococcus infection
- see provider for mgmt
- scapulae to drain debris
- keep drawing lesions with dressings
- cleanse area
- hand hygiene

41
Q

cellulitis (B/V/F, 5)

A
  • bacterial
  • localized area of inflammation may enlarge rapidly if not treated
  • redness, warmth, edema, tenderness, and pain are present
  • on rare occasions, blisters are present
  • cellulitis is often accompanied by lymphadenopathy and fever
  • lower legs, areas of persistent lymphedema, and areas of skin trauma (leg ulcers, puncture wounds) are affected
42
Q

herpes zoster (varicella zoster) (B/V/F, 5)

A
  • viral
  • lesions are similar in appearance to herpes simplex and also progress w/ weeping and crusting
  • grouped lesions present unilaterally along a segment of skin following the pathway of a spinal or cranial nerve (dermatomal distribution)
  • eruption is preceded by deep pain and itching
  • postherpetic neuralgia is common in older adults
  • areas of the anterior or posterior trunk following the involved dermatome (face, trigeminal nerve and eyes)
43
Q

herpes simplex (B/V/F, 6 including 2 types)

A
  • viral
  • grouped vesicles are present on erythematous base
  • vesicles evolve to pustules, which rupture, weep, and crust
  • older lesions may appear as punched out, shallow erosions with well defined borders
  • lesions are associated w/ itching, stinging, burning, or pain
  • type 1 classically occurs on the face
  • type 2 genitalia
    (either may develop in any area, where inoculation has occured)
44
Q

candidiasis (B/V/F, 5)

A
  • fungal
  • erythematous macular eruption occurs with isolated pustules or papules at the border (satellite lesions)
  • associated w/ burning and itching
  • oral lesions (thrush) appear as creaming white plaques on an inflamed mucous membranes
  • cracks or fissures at the corners of the mouth may be present
  • skin fold areas: perineal and perianal region, axillae, beneath breasts, and between the fingers; under wet or occlusive dressings can all be affected along with the oral or vaginal mucous membranes (table 56.6)
45
Q

pediculosis (lice) (type of disorder, 3, s/sx (2))

A

parasitic disorder
- pediculosis capitis (head lice)
- pediculosis corpris (body lice)
- pediculosis pubis (pubic, or crab, lice)

s/sx:
- pruritis and excoriation from scratching
- matting and crusting of the scalp and a foul odor indicate a probable secondary infection

46
Q

scabies (type of disorder, 1, s/sx (4))

A

parasitic disorder
- contagious skin infection caused by mite infestations, transmitted by close contact with an infested person or infested bedding

s/sx:
- intense itching
- red pruritic eruptions
- small raised burrows created by the mites
- usually affects between the fingers, wrists, elbows, knees, edges of feet, axillary folds, under breasts, near the groin, or penis/scrotal areas

extra:
- can take up to a month for sx. to appear
- neck down affected
- treatment goes on those areas
- can have scabies/lice at the same time!
- can gave itching up to severals weeks, d/t hypersensitivity to scabies

47
Q

bedbugs (type of disorder, 3, s/sx (2), tx (5+)

A

parasitic disorder
- parasite does NOT live on humans, it feeds on human blood
- insect bites a human hose at night and sucks blood for 3-10 minutes
- bite area resembles a mosquito or flea bite with a raised bite mark surrounded by a wheal

s/sx:
- bite causes an itchy discomfort
- clustered bite marks

tx:
- prevention
- prevent s/d infections d/t itching
- contact appropriate exterminators
- contact isolation precaution (PPE)
- deep contamination process if come to ER

48
Q

psoriasis (2)

A
  • chronic, autoimmune disorder that results from overstimulation of the immune system (Langerhan’s cells) in the skin that targets kertinocytes, causing increased cell division (because some degree of cellular regulation is lost) and plaque formation
  • chronic condition w/ exacerbation and remissions
49
Q

psoriasis s/sx (4, levels (3))

A
  • reddened papules or plaques covered by silvery white scales
  • bilateral distribution (elbows, knees)
  • borders between the lesions and normal skin are sharply defined
  • lesions thicken during exacerbations and extend to new body areas

levels:
- mild: <5% SBA
- mod: 5-10% SBA
- severe: >10% SBA

50
Q

psoriasis nursing interventions (nonpharm (1), pharm (3))

A

nonpharm
- urge patients and families to consider support groups

pharm
- topical steroids
- phototherapy/ultraviolet light: meds prior to lead tx. helps bind w/ DNA (decrease cellular proliferation in epidermis, 2-3x/week)
- systemic biologic & immunomodulating agents (methotexate)

SE: toxic liver, kidney, bone marrow (look at pertinent labs), avoid ETOH consumption

51
Q

skin cancer (2)

A
  • occurs as a result of failure of cellular regulation over cell division
  • most common forms: basal cell, squamous cell carcinomas
    (highly curable if detected early and treated properly)
52
Q

actinic keratosis (premalignant) (clinical manifestations (4), distribution (2), course (1), tx)

A

clinical manifestations
- small (1-10mm) macule or papule w/ dry, rough, adherent yellow or brown scale
- base may be erythematous
- associated w/ yellow, wrinkled, weather beaten skin
- thick, indurated keratoses more likely to be malignant (cancerous)

distribution
- sun exposed areas
- cheeks, temples, forehead, ears, neck, back of hands, and forearms

course
- may disappear spontaneously or reappear after treatment, slow progression to squamous cell carcinoma is possible

tx: laser therapy, topical therapeutic agents

53
Q

basal cell carcinoma (clinical manifestations (3), distribution (1), course (1))

A

clinical manifestations
- pearly papule w/ a central crater and rolled, waxy borders
- telangiectasis and pigment flecks visible on close inspection
- as it grows, it undergoes central ulceration and sometimes crusting

distribution
- sun exposed areas, esp. head, neck, and central portion of face

course
- metastasis is rare, may cause local tissue destruction; 50% recurrence rate r/t inadequate treatment

54
Q

squamous cell carcinoma (clinical manifestations (3), distribution (1), course (1), goal))

A

clinical manifestations
- rough, thickened, scaly tumor (may involve bleeding)
- indurated margins
- fixation to underlying tissue w/ deep invasion

distribution
- sun-exposed areas, esp. head, neck, ears, nose, and lower lip; sites of chronic irritation or injury (eg. scars, irradiated skin, burns, leg ulcers)

course
- rapid invasion w/ metastasis via the lymphatics occurs in 10% of cases; larger tumors are more prone to metastasis

goal: eliminate tumor, surgical tumor removal, myographic surgery, radiation, topical therapeutic creams

55
Q

melanoma (clinical manifestation (2), distribution (1), course (1))

A

clinical manifestation
- irregularly shaped, pigmented papule or plaque
- variegated colors, w/ red, white, and blue tones

distribution
- can occur anywhere on the body, esp. where nevi (moles) or birthmarks are evident; commonly found on upper back and lower legs, soles of feet and palms in dark skinned people

course
- radial growth phase followed by vertical growth phase, rapid invasion and metastasis w/ high morbidity and mortality

56
Q

skin cancer assessment (tip: ABCDE)

A

A: asymmetry of shape
B: border irregularity
C: color variation within one lesion
D: diameter greater than 6mm
E: evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, crusting)

57
Q

prevention techniques for skin cancer (6)

A
  • avoid sun exposure between 11am-3pm
  • use sunscreen w/ appropriate skin protection factor for your skin type
  • wear hat, opaque clothing, and sunglasses when you are out in the sun
  • keep a “body map” of your skin spots, scars, lesions to detect when changes have occured
  • examine your body monthly for possibly cancerous or precancerous lesions
  • seek medical advice if you note any of the ABCDE changes

eyes: cataracts can form

58
Q

skin cancer nursing interventions (nonsurgical (2), surgical (5))

A

nonsurgical mgmt
- topical or systemic chemotherapy, biotherapy, or targeted therapy
- radiation therapy

surgical mgmt
- cryosurgery
- curettage and electrodesiccation
- excisional biopsy
- mohs’ surgery
- wide excision

59
Q

the tissue destruction caused by a burn injury leads to local and systemic problems that affect (4)

A
  • fluid and electrolyte balance
  • protein losses
  • sepsis development
  • changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning
60
Q

superficial-thickness wounds (1, s/s (4), healing?)

A
  • have the least damage bc epidermis is the only part of the skin that is injured

s/sx:
- redness
- pain
- tingling and increased sensitivity to heat
- desquamation (peeling of dead skin) occurs 2-3 days after the burn

  • area heals rapidly in 3-6 days w/o a scar or other complication
61
Q

superficial partial-thickness wounds (2, s/sx (1), healing?)

A
  • caused by injury to the upper third of the dermis leaving a good blood supply
  • small vessels bringing blood to this area are injured, resulting in the leakage of large amounts of plasma, which in turn lifts the heat-destroyed epidermis, causing blister formation

s/sx:
- pink to red, painful blisters

  • heal in 10-21 days w/ no scar, but some minor pigment changes may occur
62
Q

deep partial-thickness wounds (2, s/sx (1), healing?)

A
  • extend deeper into the skin dermis and fewer healthy cells remain
  • blister uusally do not form because the dead tissue layer is thick, sticks to the underlying dermis, and does not readily lift off the surface

s/sx:
- red and dry w/ white areas in deeper parts (dry because fewer blood vessels are patent) w/ moderate edema

  • heals in 2-6 weeks, but scar formation results
63
Q

full thickness wounds (2, s/sx (2), healing?)

A
  • destruction of the entire epidermis and dermis, leaving no skin cells to repopulate
  • wound does NOT regrow, areas not closed by wound contraction require grafting

s/sx:
- hard, dry, leathery eschar forms from coagulated particles of destroyed skin with severe edema
- may be waxy, white, deep red, yellow, brown, or black

  • healing time can range from weeks to month depending on establishing a good blood supply
64
Q

deep full thickness wounds (2, s/sx (1), healing?)

A
  • extend beyond the skin and damages muscle, bone, and tendons
  • all full thickness burns need early excision and grafting

s/sx:
- charred, blackened and depressed, w/ sensation completely absent

  • grafting may not be successful
  • amputation may be needed when extremity is involved
65
Q

assessment of burn wounds (4)

A
  • assess the skin to determine the size and depth of burn injury (size of the injury is first estimated in comparison w/ the total body surface area (TBSA)
  • The rule of nines (most common method, base of 9%)
  • lund and browder method
  • the palmer method
66
Q

vascular changes resulting from burn injuries (5)

A
  • circulation to the burned skin is disrupted immediately after injury by blood vessel occlusion
  • fluid shift occurs after initial vasoconstriction as a result of blood vessels near the burn dilating and leaking fluids into the interstitial space
  • leakage of fluid and electrolytes from the vascular space continues, causing extensive edema, even in areas that were not burned, leading to weight gain
  • hypovolemia, metabolic acidosis, hyperkalemia, hyponatremia occur in the first 24-36 hours
  • fluid remobilization starts at about 24 hours after injury, when the capillary leak stops. the diuretic stage begins at about 48-72 hours after the burn injury
67
Q

cardiac changes resulting from burn injuries (5)

A
  • HR increases and cardiac output decreases because of the initial fluid shifts and hypovolemia that occur after a burn injury
  • workload of the heart and O2 demands increase w/ decreased perfusion, O2 delivery and BP -> shock
  • cardiac output may remain low until 18-36 hours after the burn injury
  • cardiac output improved w/ fluid resuscitation and reaches normal levels before plasma volume is restored completely
  • proper fluid resuscitation and support w/ oxygen prevent further complications
68
Q

pulmonary changes resulting from burn injuries (4)

A
  • respiratory problems are caused by superheated air, steam, toxic fumes, or smoke
  • respiratory damage from an inhalation injury can occur in the upper and major airways and the lung tissue and can cause edema that leads to obstruction
  • lining of the trachea and bronchi may slough 48-72 hours after injury and obstruct the lower airways
  • leaking capillaries cause alveolar edema, which can occur immediately or up to a week after the injury
69
Q

gastrointestinal and renal changes resulting from burn injuries (5)

A
  • sympathetic nervous system stress response increases secretion of epinephrine and norepinephrine, which inhibit GI motility and further reduce blood flow to the area
  • secretions and gases collect in the GI tract, causing abdominal distention
  • peristalsis decreases, and a paralytic ileus may develop
  • increased production (and loss) of heat breaks down protein and fat (catabolism), rapidly uses glucose and calories, and increases the metabolic rate and calorie needs
  • if there is inadequate blood flow, acute kidney injury can occur
70
Q

age related changes increasing complications from burn injuries (6)

A
  • thinner skin, sensory impairment, decreased mobility
  • slower healing time
  • more likely to have cardiac impairments
  • reduced inflammatory and immune responses
  • reduced thoracic and pulmonary compliance
  • more likely to have pre-existing medical conditions such as DM, kidney impairment, or pulmonary impairment
71
Q

resuscitation phase of burn injuries: emergency mgmt of burns (9)

A
  • assess airway for patency
  • administer oxygen as needed
  • cover the patient w/ a blanket and cover the wound w/ clean dry cloth
  • keep the patient on NPO status
  • elevate the extremities if no fractures are obvious
  • obtain VS
  • initiate IV line, begin fluid replacement
  • administer tetanus toxoid for prophylaxis
  • perform a head to toe assessment
72
Q

respiratory assessment of burn injuries (inspect (3), s/sx (6))

A

1) inspect the mouth, nose, and pharynx
- burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes = strong indicator that inhalation injury may be present
- burns inside the mouth and singed nasal hairs = indicate possible inhalation injury
- black particles of carbon in the nose, mouth, sputum; edema of the nasal septum; and a “smoky” smell to the patient’s breath indicate smoke inhalation

2) s/sx:
- progressive hoarseness or brassy cough
- drool or difficulty swallowing
- audible wheezing
- crowding
- stridor
- dyspnea in supine position

73
Q

cardiovascular assessment of burn injuries (4)

A
  • changes in the cardiovascular system begin immediately after the burn injury and include shock as a result of disrupted fluid and electrolyte balance
  • at first, cardiac manifestations are from hypovolemia and decreased cardiac output
  • monitor the degree of edema, assess cardiac status by measuring central and peripheral pulses, BP, cap refill, pulse ox
  • obtain baseline ECG tracings at the time of admission, continue ECG monitoring throughout the resuscitation phase
74
Q

gastrointestinal assessment of burn injuries (4)

A
  • although GI tract usually is not directly injured, changes in function occur in all burn patients
  • decreased blood flow and sympathetic stimulation reduce GI motility and promote development of a paralytic ileus
  • bowel sounds are usually reduced or absent in a patient w/ severe burns, nausea, vomiting, and abdominal distention may aslo be present if there is an ileus
  • patients w. burns of 25% TBSA or who are intubated generally require a NG tube inserted to prevent aspiration and remove gastric secretions
75
Q

genitourinary assessment of burn injuries (3)

A
  • changes in kidney function w/ burn injury are r/t decreased blood flow and cellular debris. during the fluid shift, blood flow to the kidney may not be adequate for filtration
  • when muscle damage occurs from a major burn or electrical injury, myoglobin is released from damaged muscle and circulates to the kidney, along w/ other proteins from damaged blood cells; which can contribute and cause kidney failure
  • assess kidney function and monitor intake and urine output hourly
76
Q

nursing interventions r/t respiratory issues of burn injuries (nonsurgical (4), surgical (3))

A

nonsurgical
- airway maintenance
- promotion of ventilation, gas exchange, oxygen therapy
- drug therapy
- positioning and deep breathing

surgical
- tracheostomy
- eschartomy
- chest tubes

77
Q

nursing interventions r/t cardiovascular of burn injuries (nonpharm (2), pharm (2), surgical (1))

A

nonpharm
- priority nursing interventions are carrying out fluid resuscitation and monitoring for indications of effectiveness or complications
- monitor any invasive cardiac monitoring devices

pharm
- IV fluid resuscitation
- deug therapy

surgical
- escharotomy

NUR 3020 exams (11 decks)

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