Integumentary Flashcards

1
Q

What are the manifestations of candidiasis?

A

Found in moist areas of the skin surface
white exudate
peeling inflamed areas that bleed easily
pruritic

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2
Q

What are the nursing actions for candidiasis?

A

admin topical antifungal ointment
-miconazole
-nystatin

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3
Q

What are the manifestations of Impetigo?

A

Reddish macule becomes vesicular w/ crust
erupts easily, leaving moist erosion on the skin, secretions dry, forming crusts
honey-colored crust

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4
Q

What are the nursing interventions for impetigo?

A

Admin topical bactericidal or triple antibiotic ointment
oral or parenteral antibiotics for severe cases
assist in preventing the child from itching/touching the affected area

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5
Q

What infection control measures should be taken to control impetigo?

A

HIGHLY contagious
give the pt their own washcloths
do not share towels
wash on hot w/ bleach

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6
Q

What should you educate your patient on with impetigo?

A

Hand washing!!
do not pick at crusts
avoid sharing clothing, hats, combs, brushes, towels

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7
Q

What are the clinical manifestations of pediculosis capitis? (head lice)

A

intense itching
nits (white specks) on the hair shaft
small, red bumps on the scalp

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8
Q

What are the nursing actions for head lice?

A

use 1% permethrin shampoo
teach on removal process

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9
Q

What infection control measures should be taken with lice?

A

do not share personal items (combs, brushes, hair ties, hair clips)
do not share hats

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10
Q

What should you educate your patient on with lice?

A

Remove nits w/ a fine-tooth nit comb, repeat in 7 days after shampoo tx
wash clothing and bedding in hot water w/ detergent bag items that cannot be washed into tightly sealed bags for 14 days
place items in a hot dryer for 20 min

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11
Q

What are the manifestations of diaper dermatitis?

A

bright red rash that extends gradually
fiery red & scaly areas on the scrotum, penis, & labia
pimples, blisters, ulcers, large bumps or pus-filled sores
smaller red patches that blend together
can be yeast: greater moisture w/ white exudate present (candidiasis)

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12
Q

What are the nursing interventions & teaching for diaper rash?

A

promptly remove the soiled diaper
clean the perineal area w/ a non-irritating cleanser
expose the affected area to the air to air dry
use superabsorbent disposable diapers to reduce skin exposure
apply a skin barrier such as zinc oxide, petrolatum ointment, aluminum acetate solution
- must be clean before applying
- do not wash it off w/ each diaper change
encourage frequent diaper changes
diaper rash can be a sign of neglect
do not use corticosteroid ointments

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13
Q

What are the clinical manifestations for acne?

A

lesions (comedones) are open (blackheads) or closed (whiteheads)
most common on the face, neck, back & chest
p.acne can lead to inflammation manifesting as papules, pustules, nodules or cysts

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14
Q

What are the nursing actions for acne?

A

apply warm compresses
determine if the pt is sexually active before beginning isotretinoin
monitor for behavioral changes & s/sx of depression or suicidal ideation in pts taking isotretinoin

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15
Q

What should you teach your patient about acne?

A

gently wash their face
encourage a balanced, healthy diet; sleep, rest & daily exercise; frequent shampooing
do not pick or squeeze comedones
assist in coping w/ new body-image changes
wear protective clothing & sunscreen, avoid tanning beds
reinforce the need for follow-up & monitoring of chol and triglycerides in pts taking isotretinoin
reinforce the need to take oral contraceptives

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16
Q

What are the adverse effects of isotretinoin?

A

dry skin & mucous membranes
dry eyes
decrease night vision
HA
Photosensitive
elevated chol & triglycerides
depression
SI or violent behaviors

17
Q

Who is contraindicated for isotretinoin?

A

women of childbearing age who are not taking birth control
- if sexually active, must use 2 forms of contraception for 1 month before, during, & 1 month after treatment

18
Q

What is lyme disease?

A

tick infected w/ borrelia burgdorferi

19
Q

When are the 3 stages of manifestions for lyme disease?

A

Stage 1: 3-30 days after the bite
Stage 2: 3-10 weeks after the bite
Stage 3: 2-12 months after the bite

20
Q

What are the stage 1 manifestations of Lyme disease

A

erythema migrans at site
chills, fever, itching, HA, fainting, stiffneck, muscle weakness
bull’s eye rash at the site of the bite

21
Q

What are the stage 2 manifestations of lyme disease?

A

systemic involvement begins
- neurologic, cardiac, & musculoskeletal
paralysis or weakness in the face, muscle pain, swelling in large joints (knees), fever, fatigue, splenomegaly

22
Q

What are the stage 3 manifestations of lyme disease?

A

systemic involvement is advanced
- musculoskeletal pain that includes the muscles, tendons, bursae & synovia
possible arthritis, deafness, cardiac comps & encephalopathy
abnormal muscle movement & weakness, numbness & tingling, speech problems

23
Q

What are the nursing actions for lyme disease?

A

observe the pt for 30 days after bite
single dose antibiotics for pts who meet criteria
2-3 week course for pts w/ confirmed case
doxycycline for kids 8 yrs & older
amoxicillin or cefuroxime for children under 8 years
cefuroxime for kids w/ penicillin allergy

24
Q

How do you prevent future bits?

A

avoid tall grass
use insect repellant
avoid contact w/ insects
avoid wood piles
inspect & treat pets, carpet, furniture
avoid flowery prints & bright clothing
avoid perfume & colognes

25
What is the priority for burns?
stop the burn prevent infection maintain homeostasis & body temp fluid replacement manage pain
26
What defines a 3rd-degree burn/full-thickness burn?
damage to the entire epidermis & dermis and possible damage to the subq tissue nerve endings, hair follicles & sweat glands are destroyed
27
What are the expected findings of a 3rd-degree burn/full-thickness burn?
red to tan, black, brown or waxy white in color dry, leathery appearance no blanching possibly not painful at first but as it heals, pain sensation returns
28
How long does it take for a 3rd-degree burn to heal?
weeks to months scarring is present grafting is required
29
What are the expected findings of a 4th-degree burn?
color variable no pain is present exposed bone and muscle
30
What is a thermal burn?
occurs when there is exposure to flames, hot surfaces, or hot liquids occurs w/ burns to the face & lips damage occurs to the tracheobronchial tree after inhalation of heated gases and toxic chemicals produced during combustion can be delayed 24 to 48 hours
31
What are the expected findings of a thermal burn?
wheezing increased secretions hoarseness wet rales in the lungs singed nasal hairs laryngeal edema carbonaceous secretions
32
What are the nursing interventions for minor burns?
STOP the burn: apply cool tepid water (NO ICE) AVOID using greasy lotion or butter on the burn cover burn w/ clean cloth to prevent contamination cleanse w/ mild soap & tepid water, antimicrobial ointment, apply dressing, provide analgesia
33
What should you check and why with burn patients?
Immunization status because they will need a tetanus shot if it has been >5 years since the last one
34
What are the nursing interventions for major burns?
minor burn interventions too maintain airway & vent (humidified @ 100%) replace fluids manage pain prevent infection monitor for s/sx of septic shock increase protein & calories for tissue healing increase vit. A, C and zinc body-image change coping
35
What findings should be reported with burn patients?
septic shock infection