integumentary system

7/21/2019 Integumentary System

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INTEGUMENTARYSYSTEM

Ma. Victoria J. Recinto, RN, USRN

University of the Philippines-Manila

Philippine General Hospital


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ANATOMY: SKIN

Largest sensory organ of the

o!y

S"rface area# $%-&' s("arefeet, )t# * ls

Layers# +pi!eris, eris,Hypo!eris S/ fat0


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ANATOMY: SKIN


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ANATOMY: SKIN

+pi!eral appen!ages# nails, hair,

glan!s seaceo"s 1 s)eat0

N acterial flora# Pse"!oonas,Staphylococc"s Gra positive 1

negative0, Streptococc"s

pH of 2.&-%.3 halts acterial gro)th


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ANATOMY: SKIN


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PHYSIOLOGY: SKIN$stline of !efense against

infectionsProtects "n!erlying tiss"es, organsReceives sti"li, !etects to"ch,

press"re, pain an! 4, relays info to

5NSMaintains N o!y 4


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PHYSIOLOGY: SKIN+6cretes salt, )ater an! organic

)astes

Prevents e6cessive )ater lossSynthesi7es Vit. that converts

calcitriol nee!e! for 5a

etaolisStores n"trients


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DIAGNOSTIC TESTS:

SKIN BIOPSY8or histopathologic st"!y 9ncl"!e p"nch, e6cisional, incisional 1 shave:tain infore! consent, cleanse site as

or!ere!Sen! saple to pathology la for analysisUse aseptic techni("e in !ressing site, ;eep

the !ressing for at least


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DIAGNOSTIC TESTS:

SKIN CULTURESNoninvasive proce!"reSaple is otaine! "sing sterile

applicatorViral c"lt"re is place! ie!iately

on ice

:tain saples efore startingantiiotic therapy


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DIAGNOSTIC TESTS:

WOODS LIGHT EXAM

S;in is vie)e! "n!er UV lightthro"gh a =oo!>s glass toi!entify s"perficial s;in infection

ar;en roo efore the e6a


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DIAGNOSTIC TESTS:

SKIN TESTING?!inistration of an allergen to the

s"rface of the s;in or into the !eris viascratch, patch or 9 techni("es0

@5 systeic corticosteroi!s orantihistaine t6 %! efore the test:tain infore! consent

Have res"scitation e("ipent availales@p scratch test, it ay in!"ceanaphylactic reaction


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DIAGNOSTIC TESTS:

SKIN TESTINGAeep site area !ry9f patch test )as !one, avoi! activities that

ay pro!"ce s)eating if patch loosens or

falls off, it sho"l! not e reapplie!0Recor! the site, !ate 1 tie of the test 1

the follo)-"p site rea!ing

=:8 erythea, vesicles, e!ea 1in!"ration


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RISK FACTORS:

SKIN DISORDERS+6pos"re to5heicals, poll"tants, ra!iation, s"n

9proper hygiene

5osetics 1 harsh soapsLong-ter corticosteroi!s 1 anticoag"lantsN"tritional !eficiencies+otional stress 9nfection?ging


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SKIN CANCER

Malignant lesion of the s;in,ay or ay not etastasi7e

5a"ses# chronic friction,irritation 1 UV rays6# s;in 6 B0 for 5? cells


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SKIN CANCER4ypesCasal cell# ost coon, in epi!erisS("ao"s cell# coon aong

)hites, t"or of epi!eral;eratinocytes, ets to lyph no!es

Malignant elanoa# 5? of

elanocytes, ets to rain, l"ngs,one, liver 1 s;in, fatal


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SKIN CANCER?ppearance=a6y no!"le

9rreg"lar, circ"lar, or!ere! lesion)ith h"es of tan, lac; or l"eSall, re!, no!"lar lesion

:o7ing, lee!ing, cr"sting lesion


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SKIN CANCER: Nursing

In!r"!ni#nsMonitor lesions that !o not heal or that change

characteristicsReove oles or lesions s"Dect to chronic

irritation?voi! contact )ith cheical irritants=ear layere! clothing, apply s"nscreens )hen

o"t!oors

?voi! s"n e6pos"re et)een $$a-Ep?ssist )ith s"rgical e6cision of the lesion as

prescrie!


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CONTACT DERMATITIS9nflaatory reaction after contact )ith a

specific antigen?ssessent

Pr"rit"s+!ea+rythea at contact site

9nfectionVesicles )ith !rainage


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CONTACT DERMATITIS:

Nursing In!r"!ni#ns e6treity to e!ea?pply cool, )et !ressings 1 4SC Maintain cool env>t Protect area fro tra"a, avoi! scratching 1

r"ing?ssist )ith s;in testing as or!ere! to !eterine

allergen

?voi! harsh soap, heating pa!s or lan;ets?!inister antiiotics, antipr"ritic, antihistaine 1

corticosteroi!s as or!ere!


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POISON I$Y% OAK & SUMAC eratitis fro contact )ith "r"shiol of these

plants S@S# pap"lovesic"lar lesions, severe itching 5leanse sin )ith plant oils?pply cool, )et !ressings )ith C"ro)>s sol"tion

as or!ere! to itching?pply lotion or topical corticosteroi! as or!ere!s

?!inister oral corticosteroi!s as or!ere! forsevere reaction


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LYME DISEASE

?n infectionca"se! yspirochete

Borreliaburgdorferifroa tic; in )oo!e!

area, s"rvivesy attaching tothe host0 ite


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LYME DISEASE: Ass!ss'!n

$ststage S@S6 occ"rs !ays to os. follo)ing the tic; ite

? sall re! piple !evelops, sprea!s into a ring shape!

rash

Rash ay e large or sall or none at all 8l"li;e S6s# H?, stiff nec;, "scle aches, fatig"e

&n!stage

Joint pains

Ne"rological 1 car!iac 56 Er!stage

Large Doint pains then progresses


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LYME DISEASE: Ass!ss'!n


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LYME DISEASE:

Nursing In!r"!ni#ns

Gently reove the tic; )itht)ee7ers, )ash s;in )ith antiseptic,!ispose the tic; y fl"shing it !o)n

the toiletGet a loo! test 2-3 );s after the

ite to !etect presence of !isease?!inister antiiotic if !6 confire!


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LYME DISEASE:

Nursing In!r"!ni#ns

?voi! )oo!e! grassy areas esp. inthe s"er os.

=ear long-sleeve! tops, long pants,close! shoes 1 hats )hile o"tsi!e

Spray the o!y )ith tic; repellentefore going o"tsi!e

+6aine o!y )hen ret"rning insi!e


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ERYSIPELAS & CELLULITIS

+rysipelas# ac"te s"perficial, rapi!lysprea!ing inflaation of !eris 1lyphatics ca"se! y G?CS via

arasion, ite, tra"a or )o"n!05ell"litis# s;in infection of !eris 1

S/ ca"se! y Streptococcuspyogenes


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ERYSIPELAS & CELLULITIS

?ssessentPain

9tchingS)ellingRe!ness 1 )arth


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ERYSIPELAS & CELLULITIS:

Nursing In!r"!ni#ns

Proote rest?pply )ar copress C9

?!inister antiiotics after 5@Sas or!ere!

5lean s;in : )ith antiacterialsoap


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PSORIASIS5hronic, non-infectio"s s;in inflaation

involving ;eratin synthesispsoriaticpatches

Most coon# psoriasis v"lgaris5a"ses# stress, tra"a, infection, changes

in cliate, e6acerate! y certain e!sAoener>s phenoenon# !evelopent of

lesions at the site of inD"ry scratche! ors"n"rne! area0


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PSORIASIS: Ass!ss'!n

Pr"rit"sShe!!ing, silvery, )hite scales on a

raise! re!!ene!, ro"n! pla("e on the

scalp, ;nees, elo)s, ars 1 legs,sacr"

Fello) !iscoloration, pitting, thic;ening

of nailsJoint inflaation )ith psoriatic arthritis


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PSORIASIS:

Nursing In!r"!ni#ns

aily soa;s 1 tepi!, )et copresses tothe affecte! areas to reove scales, oilor coal tar prep. ay e a!!e! to ath

)aterReove scales !"ring soa;s "sing soft

)ash cloth in gentle, circ"lar otions

apply eollient creas or salicylic aci!after ath to soften thic; scales


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PSORIASIS:

Nursing In!r"!ni#ns 4opical phara t6 4ar prep, anthralin, salicylic aci!,

corticosteroi!s, Vit. , calcipotrieneovone60, ta7arotene 4a7orac0# ca"se

slo"ghing of rapi!ly gro)ing epi!eral cells :ccl"sive !ressings post steroi! application

to its effectiveness Use plastic )raps for feet0, r"er gloves for

han!s0, sho)er cap for hea!0, plastic vinylDogging s"it if eing treate! at hoe


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PSORIASIS:

Nursing In!r"!ni#ns

9ntralesional t6 4riacinolone acetoni!e ?ristocort, Aenalog-$',

4rye60 inDection to psoriatic patches that areresistant to other fors of t6

Systeic t6 9f resistant to other fors of t6 Methotre6ate 8ole60, hy!ro6y"rea Hy!rea0 1

cyclosporine ? 5y?0Photocheot6

5oo of photosensiti7ing e!s


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PSORIASIS:

Nursing In!r"!ni#ns

9nstr"ct the ptNot to scratch the affecte! areas 1

;eep the s;in l"ricate! to itchingRecogni7e S@S6 of infection=ear light cotton clothingMe!s copliance an! avoi! :45

e!s9!entify )ays to stress


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KAPOSIS SARCOMA

S;in lesions that occ"r priarily inin!ivi!"als )ith a coproise! 9S

Slo)-gro)ing t"or, raise!,

olong, p"rplish, re!!ish-ro)nlesion, ay e ten!er or not

:rgans involve!# lyph no!es,

air)ays or l"ngs, G9 tract


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KAPOSIS SARCOMA


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KAPOSIS SARCOMA

KAPOSIS SARCOMA


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KAPOSIS SARCOMA:

Nursing In!r"!ni#ns

Stan!ar! preca"tionsProtective isolation

Prepare for ra!iation or cheot6?!inister i"not6 asor!ere! to staili7e the 9S


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HERPES (OSTER )SHINGLES*

?c"te viral infection in the !orsal nerve rootganglion ca"se! y varicella 7oster vir"s

5a"se! y reactivation or e6pos"re to vir"sor !"ring i"nocoproise! state

5ontagio"s to persons )ho have not ha!chic;enpo6

6 tests

S;in c"lt"res 1 stains?ntin"clear ? ?N?0 loo! test



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HERPES (OSTER )SHINGLES*:

Ass!ss'!n

Unilaterally cl"stere! s;in vesiclesalong peripheral sensory nerveson the tr"n;, thora6 or face

8everC"rning 1 ne"ralgiaPr"rit"sParesthesia



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Ass!ss'!n



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Ass!ss'!n



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Nursing In!r"!ni#ns

9solate the pt, stan!ar! preca"tions,contact preca"tions

?ssess ne"rovasc"lar stat"s 1 5N

V99 f"nction=:8 infectionAeep listers intact?pply acetic aci! copress, cool

)et copress 1 tepi! aths



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Nursing In!r"!ni#ns

?ssist )ith nerve loc; "sing Li!ocaine?!inister antiviral, analgesics, antian6iety,

antipr"ritics 1 corticosteroi!s as or!ere!Use an air attress 1 a e! cra!le, ;eep

env>t cool )arth 1 to"ch aggravate pain0?voi! scratching 1 r"ing the affecte!

area

=ear light)t, loose cotton clothing, avoi!)ool 1 synthetic clothing


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PARONYCHIA

9nfection of the tiss"e aro"n! the nail plate5oon aong i!!le-age! )oen 1 M

pts B0 re!ness, soreness 1 s)elling aro"n!

naile!Monitor 4, infection aro"n! nails, cell"litis?ssist )ith )ar soa;s?ssist )ith 9 1 as or!ere!?!inister antiiotic or f"ngici!al ointents

as or!ere!


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IMPETIGO Highly infectio"s, ca"se! y Gro"p ? -

heolytic Streptococc"s, possily Stapha"re"s

Pre!isposing factor# heavy infestation of

Pe!ic"losis capitis then pic; nose Pap"lovesic"lar lesions face, aro"n! o"th,

han!s, nec;, e6treities0 s"rro"n!e! y

locali7e! erythea ecoing p"r"lent an!

oo7e, foring a honey-colore! cr"st

56# ?GN


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IMPETIGO: Nursing In!r"!ni#ns5ontact isolation

5o"nicale for 2


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IMPETIGO: Nursing In!r"!ni#nsProper hygieneStrict han! )ashingUse separate to)els, linens, !ishes

)ashe! separately )ith !etergent

in hot )ater0:ral antiiotics

Penicillin0?ntiiotic ointentM"pirocin0


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BOILS

eep acterial inflaation of hair folliclesca"se! y Staph. ?"re"s Seen on the face, nec;, ars, legs 1 groin B0 re!ness 1 s)elling on s;in, ten!er 1 painf"l,

)ith yello) or )hite center at the f"r"ncle :serve strict han! )ashing?pply hot oist copress?ssist )ith 9 1

9nstr"ct pt in !aily cleanliness, "se of separateath linens?!inister antiiotics as or!ere!


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BOILS


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FROSTBITE

aage to tiss"es 1 loo! vessels as ares"lt of prolonge! e6pos"re to col!

8ingers, toes, nose 1 ears often are affecte!S@S6N"ness, paresthesiaPallorSevere pain, s)elling, erythea 1

listering once client is in a )ar env>tNecrosis 1 gangrene in severe cases

FROSTBITE:


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FROSTBITE:

Nursing In!r"!ni#ns

Han!le the tiss"es gentlyRe)ar the affecte! part rapi!ly an!

conitn"o"sly )ith )ar )ater ath *'-$'I80 for $%-&' ins. "ntil s;in fl"shing

?voi! slo) tha)ing, interr"pte! perio!s of)arth or assage

o not !eri!e listers

Leave area e6pose! initially for assessent1 then apply "l;y !ressings to provi!eprotection


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SCABIES


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SCABIES


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SCABIES 9nfestation of Sarcoptes scaiei itch ite0

8 ite "rro)s into epi!eris, lay eggs 1

!ies after 2-% );s

4he eggs hatch in E-% !ays, larvae at"re 1

coplete life cycle5ontagio"s !"ring co"rse of infestation via

!irect contact )ith infecte! person or articles

+n!eic aong schoolchil!ren 1instit"tionali7e! pop.


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SCABIES: Ass!ss'!n+rytheato"s pap"les 1 p"st"les

9ntense pr"rit"s esp. at night

4hrea!li;e, ro)nish linear

"rro)s $ c long

Secon!ary lesions# vesicles,

cr"sts, re!!ish-ro)n no!"les 1e6coriation


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SCABIES: Nursing In!r"!ni#ns?ntihistaines or topical steroi!s as or!ere!

4opical scaici!es Lin!ane crea A)ell, Scaene0 sho"l! not e "se! for

& y@o# ris; of ne"roto6icity 1 sei7"res 5rotaiton

+"ra60

=ar soap-an!-)ater athry an! cool s;in to 5NS asorption0?pply scaici!e lotion thinly fro nec; !o)n since

face 1 scalp are not affecte!0 leave for $&-&2 hrs

efore rinsingPerethrin %K +liite0# crea is assage! thoro"ghly

an! gently fro hea! to soles avoi! contact )ith eyes


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SCABIES: Nursing In!r"!ni#ns4reat all ho"sehol! eers 1 close

contacts si"ltaneo"slyStrict han! )ashing

5hange all clothing 1 e!!ing :, )ash

in !etergent )ith hot )ater, hot !ryer 1

irone! or !ry-cleane! efore re"se ites

can s"rvive "p to E3 hrs on linen0

Seal non)ashale toys 1 other ites in

plastic ag for 2 !ays


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ACNE $ULGARIS Self-liiting, inflaatory s;in !isease

involving seaceo"s glan!s Un;no)n ca"se, ay incl"!e an!rogenic infl"ence on

seaceo"s glan!s, se" pro!"ction 1 proliferationof Propionibacterium acnes en7yes )hich re!"ce

lipi!s to irritating 8?0 +6aceration coinci!e )ith

ens. cycle fro horonal

activity Heat, h"i!ity 1 e6cessive

perspiration have a role in

acne


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ACNE $ULGARIS: Ass!ss'!n


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:pen coe!oneslac;hea!s0

5lose! coe!ones)hitehea!s0

P"st"les, pap"lesNo!"les!eep scarring

ACNE $ULGARIS:


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ACNE $ULGARIS:

Nursing In!r"!ni#nsProper hygiene, s;in cleaning

etho!s not scr"ing the face,not to s("ee7e, pic; or pric; thelesions

Use pro!"cts laele! non-coe!ogenic, )ater-ase!

cosetics, not oil-ase!Use il! s"lf"r antiacterial0soap

ACNE $ULGARIS:


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Nursing In!r"!ni#ns?!inister as or!ere!#?ntiiotics oral or topical0?nti-acne crea# 4retinoin Retin-?0,

9sotretinoin ?cc"tane0 to se"pro!"ction 1 seaceo"s glan! si7e?R# cheilitis lip inflaation0, s;in

!ryness, eye !iscofort,

triglyceri!es?voi! ta;ing Vit ? if ta;ing

9sotretinoin

9proveent# after 2-3 );s of t6


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DECUBITUS ULCER

9pairent of s;in integrityLocali7e! areas of necrosis of

the s;in 1 S/ tiss"e ca"se! ypress"re

Prevention of s;in rea;!o)n is

a aDor role of the n"rse, esp.for e!ri!!en or ioile pts.


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DECUBITUS ULCER

DECUBITUS ULCER:


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DECUBITUS ULCER:

Ris+ F,-#rs

Maln"trition9ncontinence

9oilityS;in-shearingsensory perception

DECUBITUS ULCER:


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DECUBITUS ULCER:

S,g!s

$# intact, re!!ene! s;in, ret"rns to N s;incolor after $%-&' ins. of press"re relief, !onot lanche

epi!eris lost, shallo) )ith pin; or re!

ase, )ith )hite or yello) escharE# e6ten!s to !eris 1 S/ tiss"es, )ith

)hite, gray or yello) eschar at the otto,)ith p"r"lent !@c

2# e6ten!s to "scle 1 one, fo"l-selling,)ith ro)n or lac; eschar, )ith p"r"lent !@c

DECUBITUS ULCER:


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DECUBITUS ULCER:

S,g!s

DECUBITUS ULCER:


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DECUBITUS ULCER:

Nursing In!r"!ni#ns

?ssess n"tritional stat"s, provi!ea!e("ate n"tritional inta;e toproote tiss"e integrity

=:8 altere! s;in integrityRelieve or reove press"re on the

s;in

4"rn 1 reposition the pt (&hHelp the client to a"late

DECUBITUS ULCER:


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DECUBITUS ULCER:

Nursing In!r"!ni#ns

Provi!e active 1 passive R:M (


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BURN IN.URIES

5ell !estr"ction of the layers ofthe s;in 1 the res"ltant!epletion of fl"i!s 1 electrolytes


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TYPE OF BURNS

4heral# flaes, hotli("i!s@oDects, stea

5heical# strong aci!s, al;alis,organic copo"n!s

Ra!iation# UV lights, 6-rays or

ra!ioactive so"rce


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TYPE OF BURNS

+lectrical?ssess# voltage, type of c"rrent,

contact site 1 !"ration of contact?lternating c"rrent ore

!angero"s than !irect c"rrent0asso. )ith 5P arrest, ventric"lar fi,

tetanic "scle contraction, longone 1 cervical fract"re

INHALATION IN.URIES:


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S'#+! In/,0,i#n

=hen trappe! in an enclose!, hot, so;e!-fille!space?ssessent8acial "rns

S)elling of oro@nasopharyn6Singe! nasal hairs8laring nostrilsStri!or, )hee7ing, !yspneaHoarse voiceSooty caronaceo"s0 sp"t" 1 co"gh



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S'#+! In/,0,i#n



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Dir!- /!r',0 /!, in1ur2

Lo)er air)ays# y inhalation ofstea@e6plosive gases or aspiration of

scal!ing li("i!s

Upper air)ays# B0erythea, B0e!ea,"cosal listers@"lcerationostr"ctionesp. !"ring the $st&2-2< hrs

Hea! 1 nec; "rns# onitore! for air)ayostr"ction+4 int"ation



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O .U S

S'#+! P#is#ning

=hen y-pro!"cts of co"stion )ere inhale!ronchial ciliary action 1 in s"rfactant?ssessent

M"cosal e!ea of air)ays

=hee7ing

?fter several ho"rs, slo"ghing of

tracheoronchial epitheli"heorrhagic

ronchitis?RS



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CO 3#is#ning

5:# colorless,o!orless, tasteless,)ith affinity for Hg&'' greater than:&, foringcaro6yHgtiss"ehypo6ia

Cloo!Level

?ssessent

$-$'K 9paire! vis"al ac"ity

$$-&'K 8l"shing, H?

&$-E'K N@, ipaire! !e6terity

E$-2'K Vo,!i77iness,syncope

2$-%'K HR, RR

%'K 5oa, !eath


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BURN EXTENT: RULE OF NINES

Hea! an! nec;# *K4r"n; ?@P each0# $


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BURN DEPTH


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BURN DEPTH


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BURN DEPTH

$st!egree S"perficial thic;ness0Mil! to severe erythea pin; to

re!0, no listersClanches )ith press"rePainf"l, )ith tingling sensation

ease! )ith cooling0 for 2< hrsHeals in E-I !ays


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BURN DEPTH


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BURN DEPTH

&n!!egree Partial thic;ness0Large listers )ith e!ea+6treely painf"lHeals in &-E );s !eep partial

thic;ness# E-3 );s0

Grafts ay e "se! if healingprocess is prolonge!


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BURN DEPTH


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BURN DEPTH

Er!

!egree 8"ll thic;ness0eep re!, lac;, )hite, yello) or ro)n

areary )ith e!eaLittle or no painNee!s reoval of eschar 1 split or f"ll

thic;ness s;in grafting

Scarring 1 contractions li;ely to !evelopHeals in );s. to os.


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BURN DEPTH

2th!egree eep f"ll thic;ness09nvolves inD"ry to "scle 1 oneClac;, -0 pain, -0 e!ea, -0

listersHar! 1 inelastic eschar, nee!s

graftingHeals in );s. to os.


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BURN LOCATION

Hea!, nec; 1 chest# p"lo 568ace# corneal arasion

+ar# a"rical chon!ritisHan!s 1 Doints# intensive t6 to

prevent !isaility


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BURN LOCATION

Perineal area# a"tocontainationy "rine 1 feces

5irc"ferential "rns# to"rni("et-

li;e effectcopartent syn!roe5irc"ferential thora6 "rns#

ina!e("ate chest )all e6pansion 1

p"lo ins"fficiency


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PATHOPHYSIOLOGY: BURN9nD"re! tiss"e

hyperA

capillary

pereaility

Vasoactive s"stance

release

plasa seep to

tiss"es

5:, HR, CP

Hct then Er!-2th!ay0

r@t RC5

!aage 1

lossloo!vol"e

e!ea@anasarca $


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EMERGENT PHASE

Cegins# at the tie of "rn+n!s# )ith restoration of the cap.

pereaility fl"i! res"scitation0,

"s". 2


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EMERGENT PHASE

Prehospital 5areCegins# at the acci!ent scene+n!s# )hen eergency care is otaine!Reove the pt fro heat so"rce?ssess ?C5, asso. tra"a5onserve o!y heat, cover "rns )ith

sterile or clean cloth

Reove constricting De)elry 1 clothing4ransport

MANAGEMENT:


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EMERGENT PHASE

Prehospital 5are

MANAGEMENT:


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EMERGENT PHASE

Prehospital 5are

MANAGEMENT:


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EMERGENT PHASE

+ergency Roo 5are MaDor C"rns0+val"ate the !egree 1 e6tent of "rn

1 treat life-threatening con!itions

+ns"re patent air)ay, Give $''K :&Kvia non-rereather face as; asor!ere! if inhalation inD"ry iss"specte! "ntil caro6yHg levels

$%

MANAGEMENT:


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EMERGENT PHASE

+ergency Roo 5are MaDorC"rns0?ssess oropharyn6 for erythea

1 listers=:8 RR !istress, prepare

int"ation set at e!si!e

Monitor ?CG 1 caro6yHglevels

MANAGEMENT:


101/158

EMERGENT PHASE

+ergency Roo 5are MaDor C"rns09nitiate peripheral 9V access to

non"rne! s;in proi6al to anye6treity "rne! or prepare forcentral line insertion as or!ere!

=:8 hypovoleia, give 9V8 asor!ere!

9nsert 8oley cath, aintaining U: atE'-%' l@hr

MANAGEMENT:


102/158

EMERGENT PHASE

+ergency Roo 5are MaDor C"rns0Maintain NP: stat"s9nsert NG4 as or!ere! to reove

gastric secretions 1 prevent aspiration?!inister tetan"s prophyla6is, paine!s as or!ere!

Prepare for escharotoy or

fasciotoy as or!ere!

MANAGEMENT:


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EMERGENT PHASE

+ergency Roo 5are Minor C"rns09nstr"ct pt# follo)-"p care, active

R:M, )o"n! care

?!inister as or!ere!Pain e!s# Morphine or eerol:ral analgesics

4etan"s prophyla6is

MANAGEMENT:


104/158

EMERGENT PHASE

+ergency Roo 5are Minor C"rns0=o"n! care# cleansing, !eri!ing

loose tiss"e, application or topicalantiicroial crea 1 sterile!ressing

?!inister as or!ere! 9nstr"ct pt#follo)-"p care, active R:M, )o"n!

care

MANAGEMENT:


105/158

RESUSCITATI$E PHASE

Cegins# )ith initiation of fl"i!s+n!s# )hen cap. integrity

ret"rns to near-N levels 1 large

fl"i! shifts Goal# aintain a!e("ate

circ"lating loo! vol"e 1aintaining vital organ perf"sion

MANAGEMENT:


106/158

RESUSCITATI$E PHASE

8l"i! Res"scitation plain LR0Par;lan! Ca6ter0 8or"la2l o!y )t ;g0 4CS? "rne!9nf"se in $st< hrs post "rn in the &n!1 Er!< hrs post "rn

Mo!ifie! Croo;e 8or"la&l o!y )t ;g0 4CS? "rne!

9nf"se in $st< hrs post "rn in ne6t $3 hrs post "rn

MANAGEMENT:


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RESUSCITATI$E PHASE

Goal# U: of E'-%' l@hr ostsensitive noninvasive assessentparaeter for 5: 1 tiss"e perf"sion0

:ther paraeters# stale VS,palpale peripheral p"lses, clearsensori"

9V8 rate# a!D"ste! !epen!ing on U:,

ser" electrolytes 1 Hg 1 Hct levels

MANAGEMENT:

S SC S


108/158

RESUSCITATI$E PHASE

+levate H:C to E'for face 1 hea!"rns 9nitiate +5G onitoringMonitor 4, =:8 infection 9nitiate protective isolation, strict H=,

aseptic techni("e, PP+Shave@c"t hair aro"n! )o"n! argins

=eigh : e6pect )t gain of $%-&' ls inthe $stI& hrs0

MANAGEMENT:

RESUSCITATI$E PHASE


109/158

RESUSCITATI$E PHASE

=:8 stress "lcer, a!inister antaci!s, H&receptor antagonists, S"cralfate 5arafate0 asor!ere!

?"sc"ltate o)el so"n!s for ile"s, =:8a!oinal !istention

Monitor stools for occ"lt loo!:tain "rine specien for yogloin 1 Hg

levels

+levate circ"ferential "rns of the e6treitieson pillo)s aove heart level to e!ea

MANAGEMENT:

RESUSCITATI$E PHASE


110/158

RESUSCITATI$E PHASE

Monitor p"lses 1 cap. refill of !istale6treitiesAeep the roo 4 )ar

Place the pt on an air-fl"i!i7e! e!an! a "se of e! cra!le to ;eepsheets off the pt>s s;in

Prepare the client for 6-ray to r@otra"a, fract"res

MANAGEMENT:

RESUSCITATI$E PHASE


111/158

RESUSCITATI$E PHASE

Pain anageent?!inister orphine or eerol

9V, esp. efore painf"l proce!"res

?voi! 9M or S/ ro"tes sinceasorption thro"gh soft tiss"e is"nreliale

?voi! giving e!s po eca"se ofG9 !ysf"nction

MANAGEMENT:

RESUSCITATI$E PHASE


112/158

RESUSCITATI$E PHASE

N"trition4o proote )o"n! healing 1

prevent infection since CMR is 2'-

$'' higher than NMaintain on NP: "ntil o)elso"n!s ret"rn

5an e given via NG4, PPN or 4PNHigh 5H:N, 5H:, fats 1 vit.

MANAGEMENT:

RESUSCITATI$E PHASE


113/158

RESUSCITATI$E PHASE

+scharotoyLength)ise incision a!e thro"gh the "rn

eschar to relieve constriction, press"re toiprove circ"lation circ"ferential "rns0

1 to iprove ventilation thora60one at e!si!e, no anesthesia?ssess 5MS 1 lee!ing pac; )ith sterile,

fine esh ga"7e for &2 hrs0

?pply antiacterial ointent to the site asor!ere!

MANAGEMENT:

RESUSCITATI$E PHASE


114/158

RESUSCITATI$E PHASE

8asciotoy?n incision e6ten!ing thro"gh the S/ 1

fasciaone if a!e("ate tiss"e perf"sion !oes not

ret"rn after escharotoyone in :R "n!er G??ssess 5MS 1 lee!ing pac; )ith sterile,

fine esh ga"7e for &2 hrs0?pply antiacterial ointent to the site as

or!ere!

8?S59:4:MF


115/158

MANAGEMENT:

ACUTE PHASE
http://www.uwec.edu/kin/aidil/images/compsyn1.JPG


116/158

ACUTE PHASE

Cegins# )hen the pt isheo!ynaically stale, cap.pereaility is restore! 1 !i"resisocc"rs "s". 2


117/158

ACUTE PHASE )W#un4 C,r!*

M+4H: ?V?N-4?G+

9S?-V?N4?G+

:P+N?ntiicroialcrea applie!($&h, )o"n!left open to theair )itho"t a!ressing

Vis"ali7ation ofthe )o"n!

+asier oility1 Doint R:M

Siplicity in)o"n! care

Hypother-ia

MANAGEMENT:

ACUTE PHASE )W 4 C *


118/158


M+4H: ?V?N4?G+ 9S?V?N-4?G+

5L:S+

=ith ga"7e

!ressings applie!(


119/158


Hy!rotherapy5leanse! y iersion, sho)ering,

spraying for E' ins. to prevent Na loss fro )o"n!, heat loss,lee!ing, pain 1 stress

Sho"l! e pree!icate! eforeproce!"re

Not !one for heo!ynaically"nstale pt 1 )ith s;in grafts

MANAGEMENT:



120/158


eri!eentReoval of eschar to prevent

acterial proliferation to proote)o"n! healing

May e echanical, en7yatic ors"rgical

P4 or 84 "rns# )o"n! is cleanse!

1 !eri!e!, topical antiicroial areapplie! : or C9

MANAGEMENT:

ACUTE PHASE )W 4 C0 *


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ACUTE PHASE )W#un4 C0#sur!*

Prevents infection, fl"i! loss,contract"res prootes healingPerfore! on the %thto &$st!ay

!epen!ing on "rn e6tent

MANAGEMENT:



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4eporary )o"n! coveringsCiological?nion 8ro placenta, change! (2< hrs

?llograft hoograft onate! h"an ca!aver s;in fro s;in

an;0

=:8 infection e6"!ate0 ReDection can occ"r )ithin &2 hrs

MANAGEMENT:



123/158


4eporary )o"n! coveringsCiologicalenograft hoograft Porcine s;in after sla"ghter 1

preserve! ReDection can occ"r )ithin &2-I& hrs

Ciosynthetic or Synthetic

4ransparent or transl"cent !ressings=:8 for infection

MANAGEMENT:



124/158


?"tograftingProvi!es peranent )o"n! coverageS"rgical reoval of thin layer of pt>s

"n"rne! s;in then applie! to e6cise!"rn )o"n!

=:8 lee!ing prevent s;ina!herence0

9oili7e! for E-I! to attach to)o"n! e!0

MANAGEMENT:



125/158


MANAGEMENT:



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5are to the graft site+levate 1 ioili7e graft siteAeep site free fro press"re?voi! )t earing=:8 infection, heatoa or

fl"i! acc""lation

MANAGEMENT:



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5are to the graft site9nstr"ct the client to#?voi! "sing faric softeners 1

harsh !etergents in the la"n!ryL"ricate s;in )ith cocoa "tter

as or!ere!, protect s;in fro

s"nlightUse splints 1 s"pport garents

MANAGEMENT:



128/158


5are to the !onor siteMoist !ressing is applie! at the tie

of s"rgery to aintain press"re 1stop any oo7ing

?pply single-layer ga"7e ipregnate!)ith petrolat" or )ith iosynthetic!ressing s"ch as Ciorane

Aeep the !onor site clean, !ry 1 freefro press"re

MANAGEMENT:



129/158


5are to the !onor site?voi! scratching the site?pply l"ricating lotions to soften

the area 1 itching after the!onor site is heale!Site can e re"se! once healing

has occ"rre! "s". I-$2 !ays)ith proper care0

MANAGEMENT:

ACUTE PHASE )PT*


130/158

ACUTE PHASE )PT*

9n!ivi!"ali7e! progra of splinting,positioning, e6ercises, a"lation1 ?Ls !one early to a6ii7ef"nctional 1 cosetic o"tcoes

R:M e6ercises to e!ea 1aintain strength 1 Doint f"nction

?"late the pt to aintain L+strength

MANAGEMENT:

ACUTE PHASE )PT*


131/158

ACUTE PHASE )PT*

?pply splints to aintain proper Dointposition 1 prevent contract"resStatic splints are applie! !"ring perio!s

of ioili7ation, !"ring sleeping 1 for

pt )ho can>t aintain proper positioningynaic splints e6ercise the affecte!Doint?voi! press"re to s;in areas )ith

splinttiss"e 1 nerve !aage

MANAGEMENT:

ACUTE PHASE )PT*


132/158

ACUTE PHASE )PT*

Scarring is controlle! y elastic)raps 1 an!ages that applycontin"o"s press"re to the healings;in )hen v"lnerale to shearing

?nti"rn scar s"pport garentsare )orn &E hrs@!ay "ntil the "rnscar tiss"e has at"re!, )hich

ta;es $< os.- &yrs

MANAGEMENT:

REHABILITATI$E PHASE


133/158


8inal phase of "rn care:verlaps )ith ac"te care phase,

goes eyon! hospitali7ation

MANAGEMENT:



134/158


GoalsPt )ill gain in!epen!ence 1

a6ial f"nctions

Proote )o"n! healingMinii7e !eforities

strength 1 f"nctionProvi!e eotional s"pport

NCLEX5CG 6UESTIONS


135/158

NCLEX5CG 6UESTIONS

4he n"rse is revie)ing the health carerecor! of the clients sche!"le! to seen atthe health care clinic. 4he n"rse !eterinesthat )hich of the follo)ing in!ivi!"als is at

the greatest ris; for !evelopent of aninteg"entary !isor!erO

?. ?n ol!er feale

C. ?n a!olescent

5. ?n o"t!oor constr"ction )or;er. ? physical e!"cation teacher

NCLEX5CG 6UESTIONS


136/158

NCLEX5CG 6UESTIONS

4he n"rse prepares to assist the physicianto e6aine the client>s s;in )ith a =oo!>s

light. 4he n"rse incl"!es )hich of the

follo)ing in the plan for this proce!"reO

?. :tain an infore! consent.

C. ar;en the roo for the e6aination.

5. Shave the s;in an! scr" )ith povi!one-io!ine

sol"tion.. Prepare a local anesthetic.


137/158

NCLEX5CG 6UESTIONS


138/158

NCLEX5CG 6UESTIONS

4he n"rse provi!es !ischarge instr"ctions toa client follo)ing patch testing. =hichstateent if a!e y the client )o"l!in!icate the nee! for f"rther instr"ctionO

9 )ill ret"rn to the clinic in & !ays for the initialrea!ing.Q 9f the patch coes off, 9 nee! to reapply it.Q 9 nee! to avoi! activities that )ill ca"se e to

s)eat.Q 9 nee! to ;eep the test sites !ry at all the ties.Q

NCLEX5CG 6UESTIONS


139/158

NCLEX5CG 6UESTIONS 4he cap n"rse prepares to instr"ct a gro"p of

chil!ren ao"t Lye !isease. =hich of the

follo)ing inforation )o"l! the n"rse incl"!e in

the instr"ctionsO Lye !isease can e contagio"s y s;in contact )ith an

infecte! in!ivi!"al.

Lye !isease can e ca"se! y inhalation of spores fro

ir! !roppings.

Lye !isease is ca"se! y containation fro cat feces.

Lye !isease is ca"se! y a tic; carrie! y !eer.

NCLEX5CG 6UESTIONS


140/158

NCLEX5CG 6UESTIONS 4he client is !iagnose! )ith stage $ of Lye

!isease. 4he n"rse assesses the client for

)hich characteristics of this stageO Signs of ne"rological !isor!ers

+nlargeent an! inflae! Doints ?rthralgias

8l"-li;e syptos

NCLEX5CG 6UESTIONS


141/158

NCLEX5CG 6UESTIONS ? feale client arrives at the health care clinic an!

tells the n"rse that she )as D"st itten y a tic; an!)o"l! li;e to e teste! for Lye !isease. 4heclient tells the n"rse that she reove! the tic; an!fl"sh it !o)n the toilet. =hich of the follo)ingn"rsing actions is ost appropriateO

Refer the client for loo! test ie!iately. 9nfore! the client that there is not a test availale for

Lye !isease. 9nstr"ct the client to ret"rn in 2 to 3 )ee;s to e teste!

eca"se testing efore this tie is not reliale. 4ell the client that testing is not necessary "nless

arthralgia !evelops.

NCLEX5CG 6UESTIONS


142/158

NCLEX5CG 6UESTIONS 8ollo)ing !iagnosis of stage $ of Lye

!isease, the n"rse )o"l! anticipate that

)hich of the follo)ing )ill e part of the

treatent plan for the clientO

No treatent "nless syptos !evelop. ? E-)ee; co"rse of oral antiiotic therapy.

4reatent )ith intraveno"sly a!inistere!

antiiotics.

aily oateal aths for a perio! of & )ee;s.

NCLEX5CG 6UESTIONS


143/158

NCLEX5CG 6UESTIONS ? 5" Sco"t lea!er )ho is a n"rse is preparing a

gro"p of 5" Sco"ts for an overnight caping trip

instr"cts the sco"ts ao"t the etho!s to prevent

Lye !isease. =hich stateent y one of the 5"

sco"ts in!icates a nee! for f"rther instr"ctionsO 9 sho"l! not "se insect repellents eca"se it )ill attract

tic;s.Q

9 sho"l! )ear long-sleeve! tops an! long pants.Q

9 nee! to ring a hat to )ear !"ring the trip.Q

9 nee! to )ear close! shoes an! soc;s that can e p"lle!

"p over y pants.>

NCLEX5CG 6UESTIONS


144/158

NCLEX5CG 6UESTIONS 4he client )ith ac("ire! i"no!eficiency

syn!roe is !iagnose! )ith c"taneo"sAaposi>s sarcoa. Case! on the !iagnosis,the n"rse "n!erstan!s that this has een

confire! y )hich of the follo)ingO ?ppearance of re!!ish l"e lesions note! on thes;in.

S)elling in the lo)er e6treities

P"nch iopsy of the c"taneo"s lesions S)elling in the genital area.

NCLEX5CG 6UESTIONS


145/158

NCLEX5CG 6UESTIONS =hich of the follo)ing in!ivi!"als is least

li;ely at ris; for the !evelopent of Aaposi>s

sarcoaO ? ale )ith a history of sae-se6 partners.

? ;i!ney transplant client ? client receiving antineoplastic e!ications.

?n in!ivi!"al )or;ing in an environent )here

e6pos"re to asestos e6ists.

NCLEX5CG 6UESTIONS


146/158

NCLEX5CG 6UESTIONS 4he n"rse prepares to care for a client )ith

ac"te cell"litis of the lo)er leg. 4he n"rse

anticipates that )hich of the follo)ing )ill e

prescrie! for the clientO

=ar copresses to the affecte! area 5ol! copresses to the affecte! area

9nterittent heat lap treatents 2 ties !aily.

?lternating hot to col! copresses contin"o"sly

NCLEX5CG 6UESTIONS


147/158

NCLEX5CG 6UESTIONS 4he clinic n"rse assesses the s;in of a

)hite client )ith a !iagnosis of psoriasis.4he n"rse "n!erstan!s that )hichcharacteristic is associate! )ith this s;in

!isor!erO 5lear, thin nail e!s Silvery )hite scaly patches on the scalp, elo)s,

;nees, an! sacral regions

:ily s;in an! no-episo!es of pr"rit"s Re!-p"rplish scaly lesions.

NCLEX5CG 6UESTIONS


148/158

NCLEX5CG 6UESTIONS 4he clinic n"rse notes that the physician

has !oc"ente! a !iagnosis of herpes7oster shingles0 in the client>s chart. Case!on an "n!erstan!ing of the ca"se of this!isor!er, the n"rse )o"l! !eterine that

this !efinitive !iagnosis )as a!e follo)ing)hich !iagnosis testO

S;in iopsy. =oo!>s light e6aination.

5"lt"re of the lesion. Patch test

NCLEX5CG 6UESTIONS


149/158

NCLEX5CG 6UESTIONS 4he n"rse is assigne! to care for a client

)ith herpes 7oster shingles0. =hich of the

follo)ing characteristics )o"l! the n"rse

e6pect to note )hen assessing the lesions

of this infectionO ? generali7e! o!y rash

Sall, l"e-)hite spots )ith a re! ase

? fiery re!, e!eato"s rash on the chee;s 5l"stering s;in vesicles.

NCLEX5CG 6UESTIONS


150/158

C 5CG 6U S O S 4he n"rse anager is planning the clinical

assignents for the !ay. 4he n"rseanager avoi!s assigning )hich of thefollo)ing staff eers to the client )ith

herpes 7osterO 4he n"rse )ho never ha! "ps ?n e6perience! registere! n"rse )ho never ha!

chic;enpo6.

4he n"rse )ho never ha! roseola 4he n"rse )ho never ha! Geran easles.

NCLEX5CG 6UESTIONS


151/158

6 4he health e!"cation n"rse provi!es instr"ctions to a

gro"p of clients regar!ing eas"res that )ill assist inpreventing s;in cancer. =hich stateent if a!e ya client in!icates a nee! for f"rther e!"cationO

9 )ill "se s"nscreen )hen participating in o"t-!oor

activities.Q 9 )ill e6aine y o!y onthly for any lesion that

ay e s"spicio"s. 9 )ill )ear hat, opa("e clothing, an! s"nglasses

)hen in the s"n.Q 9 )ill avoi! the s"n e6pos"re after Ep.Q

NCLEX5CG 6UESTIONS


152/158

6 4he n"rse is preparing to care for a "rn

client sche!"le! for an escharotoyproce!"re eing perfore! on a thir!-!egree circ"ferential ar "rn. 4he n"rse

"n!erstan!s that the anticipate! therape"tico"tcoe of the escharotoy is Cris; lee!ing fro the site 8oration of gran"lation tiss"e

ecreasing e!ea foration Ret"rn of the !istal p"lses

NCLEX5CG 6UESTIONS


153/158

6 4he n"rse is caring for a client )ho

s"staine! &n!- an! Er!-!egree "rns on theanterior lo)er legs an! anterior thora6.=hich of the follo)ing !oes the n"rse

e6pect to note !"ring the eergent phase ofthe "rn inD"ryO ecrease! HR 9ncrease! CP

+levate! Hct levels 9ncrease! "rinary o"tp"t

NCLEX5CG 6UESTIONS


154/158

4he n"rse is caring for a client )ho s"ffere!an inhalation inD"ry fro a )oo! stove. 4hecaron ono6i!e loo! report reveals alevel of $&K. Case! on this level, the n"rse)o"l! anticipate )hich of the follo)ing signsin the clientO

8l"shing i77iness

4achycar!ia 5oa

NCLEX5CG 6UESTIONS


155/158

4he client arrives at the +R follo)ing a "rninD"ry that occ"rre! in the aseent athoe. ?n inhalation inD"ry is s"specte!.=hich of the follo)ing )o"l! the n"rse

anticipate to prescrie! for the clientO $''K o6ygen via an aerosol as; o6ygen via nasal cann"la at $% LPM $''K ocygen via tight fitting, non-rereather face

as; o6ygen via nasal cann"la at $' LPM

NCLEX5CG 6UESTIONS


156/158

4he n"rse is a!inistering 9V fl"i!s as prescrie!

to a client )ho s"staine! &n!- an! Er! !egree "rninD"ries of the ac; an! legs. 9n eval"ating thea!e("acy of fl"i! res"scitation, the n"rse"n!erstan!s that )hich of the follo)ing )o"l!

provi!e the ost reliale in!icator for !eteriningthe a!e("acyO Vital signs Urine o"tp"t Peripheral p"lses Mental stat"s

NCLEX5CG 6UESTIONS


157/158

4he n"rse is caring for a client follo)ing an

a"tograft an! grafting to a "rn )o"n! on

the right ;nee. =hich of the follo)ing )o"l!

the n"rse anticipate to e prescrie! for the

clientO 9oili7ation of the affecte! leg

:"t of e!

Placing the affecte! leg in a !epen!ent position Cathroo privileges

NCLEX5CG 6UESTIONS


158/158

4he a!"lt )as "rne! as a res"lt of an e6plosion. 4he

"rn initially affecte! the client>s entire faceanterior half of the leg0, an! the "pper half of the

anterior torso an! there )ere circ"ferential "rns

to the lo)er half of oth of the ars. 4he client>s

clothes ca"ght on fire, an! the client ran, ca"sings"se("ent "rn inD"ries to the posterior s"rface of

the hea! an! the other half of the posterior torso.

Using the R"le of Nines, )hat )o"l! e the e6tent

of the "rn inD"ryO

integumentary system

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