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Flashcards in Integumentary Deck (57)
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Common Skin Disorders: Assessment

▫ Present health status
▫ Past medical history
▫ Inspection of the entire skin for color and lesions
▫ Palpate skin for temperature, texture, moisture, and turgor


Common Skin Disorders

• Most treated by self-care at home
• Focus of treatment is identifying, modifying, or eliminating precipitating factors
• Diagnosis
▫ Culture
▫ Skin scrapings
▫ Biopsy
▫ Ultrasound tests


Infections/ Infestations: Assessment

▫ History of contact
▫ Living conditions
▫ Chronic illnesses
▫ Inspect skin, hair, mucous membranes  Note location, appearance, and size of lesions


Infections/ Infestations

• Treatment focused on identifying causative agent
• Administer medication to kill bacteria or eradicate the organism
• Prevent secondary infection
• Environmental surveillance and control


Infections/ Infestations: Treatment

• Parasitic infestations
▫ Topical agents to kill the parasite
• Complementary therapy
▫ Tea tree oil


Infections/ Infestations: Treatment

• Bacterial infections
▫ Antibiotics—topically or systemically
• Fungal infections
▫ Antifungal agents—topically or systemically
• Viral infections
▫ Antiviral agents
▫ Medications to relieve pain and pruritis


Infections/ Infestations: Nursing Care

• Acute Pain
• Disturbed Sleep Pattern
• Risk for Infection


Atopic Dermatitis

• Corticosteroids
• Antihistamines
• Antibiotics
• Dietary
• Lifestyle adaptations



• Tar soaps
• Photo therapy
• Topical agents
• Systemic Agents


Common Skin Disorders

• Pruritis - medications and treatments
▫ Antihistamines
▫ Tranquilizers—stress related to pruritis
▫ Antibiotics
▫ Topical steroids
▫ Therapeutic baths


Common Skin Disorders

Complimentary therapy
▫ Aloe
▫ Goldenseal
▫ Peppermint oil


Common Skin Disorders: Nursing Care

• Impaired Skin Integrity
▫ Strategies to relieve itching
▫ Therapeutic baths
• Disturbed Body Image
▫ Trusting relationship
▫ Self-perception
▫ Involvement of family
• Deficient Knowledge
▫ Medication administration


Pressure Ulcers

• Goal is prevention
• Laboratory tests to determine infection
• Topical and systemic antibiotics
• Surgical debridement
• Specialty dressings and beds


Pressure Ulcers: Assessment

▫ Identify patients at risk
▫ Describe appearance
▫ Measure size and depth
▫ Braden Skin Assessment


Skin Breakdown

• Altered nutrition less than body requirements
• Incontinence
• Chronic illness


Pressure Ulcers: Nursing Care

• Risk for Impaired Skin Integrity
▫ Minimize risk
▫ Conduct systematic inspection
▫ Keep skin clean and manage incontinence
▫ Minimize environmental factors
▫ Minimize friction and shearing forces


Pressure Ulcers: Nursing Care

▫ Maintain adequate nutritional intake
▫ Maintain activity level
▫ Teach client to shift weight
▫ Use positioning devices, pillows
▫ Keep head of bed at lowest position
▫ Use specialty devices


Skin Disorders: Teaching

• Supportive role
• Report complications of treatments
• Proper medication administration
• Care to facilitate healing and eliminate spread of infection
• Dressing changes and direct care of skin lesions
• Nutrition
• Environmental control
• Prevention of pressure ulcers in clients cared for at home


Phases of Burn Management

• Prehospital Care
• Emergent (Resuscitative)
• Acute
• Rehabilitative


Prehospital Care

• Remove the person from the source of the burn and stop the burning process
• The caregiver must be protected from becoming part of the incident
• Electrical Injuries
- Remove client from contact of source
• Chemical Injuries
- Brush solid particles off the skin - Water lavage


Prehospital Care

• Small Thermal Burns
- Cover with clean, cool, tap water- dampened towel
• Large Thermal Burns
- Airway, breathing, and circulation
• Wound Care
- Do not immerse in cool water or pack with ice
- Wrap in clean, dry sheet or blanket - Remove burned clothing


Emergent Phase

• Emergent phase is the period of time required to resolve the immediate problems resulting from burn injury
• From burn onset to 5 or more days
• Usually lasts 24-48 hours
• The phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begin


Emergent Phase Nursing and Collaborative Management: Airway Management

- Early nasotracheal or endotracheal intubation
- Escharotomies of the chest wall
- Fibre-optic bronchoscopy
- Humidified air and 100% oxygen


Emergent Phase Nursing and Collaborative Management: Fluid Therapy

- Two large-bore IV lines
- A cut down is a final measure
- Parkland (Baxter) formula for fluid replacement
- Colloidal solutions


Emergent Phase Nursing and Collaborative Management: Wound Care

- Cleansing
• Can be done in a hydrotherapy tub, cart shower, shower, or bed
- Debridement
• May need to be done in the OR
• Loose necrotic skin is removed


Emergent Phase Nursing and Collaborative Management: Wound Care

- Immersion in a tank or Shower
• Open method
• Burn is covered with a topical antibiotic with no dressing over the wound
• Multiple dressing changes
• Sterile gauze dressings are laid over a topical antibiotic
• The dressings may be changed from 2 - 3 times every 24 hours, to once every 3 days


Wound Management

• Splints used to prevent contractures
• Uniform pressure garments
▫ Reduces hypertrophic scarring
▫ May be required to wear for 6 months to 1 year postgraft


Emergent Phase Nursing and Collaborative Management: Wound Care

- Allograft or homograft skin
• Commonly used
• Rejection eventually occurs


Emergent Phase Nursing and Collaborative Management: Other Care Measures

Facial care
- Hands and arms should be extended and elevated on pillows or slings
- Ears should be kept free of pressure
• No use of pillows
• Performed by the open method
- Eye care for corneal burns
• Done with slightly warmed physiological saline rinses as often as every hour


Emergent Phase Nursing and Collaborative Management: Other Care Measures

- Head can be elevated using a donut roll
- Perineum must be kept as clean and dry as possible
- Routine lab tests
- Early ROM exercises