Passpoint: integumentary

A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure?

"Apply sunscreen even on overcast days." Sunscreen should be applied even on overcast days because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 3 p.m. and not just until noon. Sun exposure should be minimized during these hours. A sunscreen with a sun protection factor of at least 15 should be used. Sitting in the shade when at the beach does not guarantee protection against sun exposure, because sand, concrete, and water can reflect more than half the sun's rays onto the skin.

tetracycline instructions

"Take the drug on an empty stomach." take tetracycline on an empty stomach because certain foods, such as dairy products, can bind with the drug, preventing its absorption.

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care?

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. A client with electrical burns based on energy and potential damage to the heart needs cardiac monitoring.

Steven Johnson Syndrome (SJS)

A rare, serious disorder of the skin and mucous membranes. A medical emergency, this is often a reaction to medication or an infection. Flu-like symptoms appear first. A painful rash that spreads and blisters follows.

diazepam

Antianxiety Agent

Gamma benzene hexachloride

Gamma benzene hexachloride is a pediculicide used to treat lice infestation.

what fluid should be given first to burn pt?

Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn.

use of restraints

RN must first verify prescription from PCP

Squamous cell carcinoma

Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration.

melanoma

The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma.

Tinea corporis (ringworm); question to ask in hx

do you have any pets? An infected pet may be the source of this infection.

rules of 9s for burns

face 4.5% arms 4.5% each legs 9% each anterior 18% posterior 18% genitals 1%

risk factors for malignant melanoma

freckles light-colored eyes and skin history of severe sunburn presence of large moles

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury.

Endocrine glands secrete

hormones

how do you wash clothing infected with scabies?

hot water

to prevent transmission of scabies in hospital

isolate the client's bed linens until the client is no longer infectious - usually 24hrs after tx begins

intervention for immobile pt

keeping the pt's skin clean and dry

pressure ulcer in darker skin patients, assessing for stage 1 PU

look for darker area; When assessing a client with dark skin for the presence of a pressure ulcer, the nurse should observe for skin that is darker, brownish, purplish, or bluish compared to surrounding skin.

pediculicides

neurotoxins used to tx scabies

ebaceous glands secrete

oil (sebum)

meperidine

opioid for pain control

Steven Johnson Syndrome (SJS) priority finding

oral temperature of 102.2°F (39°C) Infection and sepsis are life-threatening complications for a client with Stevens-Johnson syndrome. An elevation in the client's temperature is a priority assessment finding and requires immediate action by the nurse.

aminoglycoside gentamicin sulfate SEs

ototoxicity and nephrotoxicity

to prevent wound infection

pour wound cleaner from the clean end of wound to the dirty end

Sudoriferous glands secrete which type of substance?

sweat

Atopic Dermatitis (Eczema)

use a topical skin moisturizer daily to help keep the skin hydrated. bathe daily. To minimize irritation, the client should wear only cotton fabrics. The client should maintain a room temperature between 68° F (20° C) and 72° F (22.2° C).

pt with scabies and lives with family

"All family members need to be treated." When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

shingles care

-diphenhydramine 25 mg by mouth every 6 hours PRN -calamine lotion applied to the affected areas -cool, wet compresses to the affected areas -acetaminophen 325 mg by mouth every 6 hours PRN -diversionary activities to prevent client scratching Diphenhydramine is an antihistamine that reduces allergic reactions, calamine lotion is a topical antipruritic, and acetaminophen is an analgesic. These medications may help increase client comfort by reducing pain, inflammation, and itching, which, in turn, may reduce client scratching and potentially spreading the virus. Cool wet compresses also relieve itching and pain.

Basal cell carcinoma

Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.

goal following serious thermal burn

F&E balance After maintaining respirations, the most important and immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis.

LE with cellulitis; instruction

Instruct the client to elevate the left leg when sitting in the chair. The client has cellulitis and should elevate the affected area above heart level. Ambulation stimulates circulation and promotes deposition of pathogens in other areas of the body. Alcohol and perfumed soaps are drying to the skin. Massaging lower extremities could dislodge a clot.

new grad nurse competency

The new graduate would be competent to perform skills such as sterile dressing change taught in school (a client who requires a dressing change of a pressure ulcer). Clients whose care requires more experience, such as complex skills, and education, such as admission assessments, pre-procedure teaching, and discharge teaching, should be assigned to more experienced RN staff members because these nurses are aware of the organizational procedures and have completed them routinely.

mafenide

The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns

Together, ceruminous and sebaceous glands secrete

cerumen.

rabies

contact precautions

rabies precaution level

contact precautions

advantage of using biologic burn grafts such as porcine (pigskin) grafts

promote the growth of epithelial tissue.

recovery from Infected abdominal wound. what to eat to promote healing and prevent infection?

protein, vit c, fruits, veggies, and carbs

red nodule with scaly crust on the back

could be a Squamous cell carcinoma; notify PCP

burn injury pt at risk for what?

curling's ulcer; GI ulceration that can occur in burn pts d/t hypersecretion of gastric acid

postoperative wound evisceration

Cover the area with sterile gauze that is moistened with sterile saline solution. Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection. The client should be positioned with the legs bent to relax the abdominal muscles.

stasis ulcers; appropriate pt goals

Increase oxygen to the tissues. Prevent direct trauma to the ulcer. Prevent infection. Reduce pain. The underlying pathophysiology in stasis ulcers of the skin surface is a result of inadequate oxygen and other nutrients to the tissues because of edema and decreased circulation. The nurse should first initiate care that will increase oxygen and improve tissue integrity. It is also important to prevent trauma to the tissues and prevent infections, which result from decreased microcirculation that limits the body's response to infection. Stasis ulcers are painful. The nurse can administer prescribed analgesics 30 minutes before changing the dressing. There is no indication that the client's overall nutrition needs to be improved.