Med Surg E6 SG CH 24-26, 46-48

REVIEW CH 25- Chart 25-10: Pt and Family Education on Preventing Spread of MRSA (p.469)

-Avoid close contact with others, including participation in contact spots, until the infection has cleared. -Keep the infected skin area covered with clean, dry bandages. -Place soiled bandages in plastic bag and seal it closed before placing it in regular trash. Do the same with gloves used and turn inside out. -Shower daily, using antibacterial soap. Urge family to shower daily as well with antibacterial soap. -Wash all uninfected skin areas before washing the infected area or use fresh washcloth to wash uninfected areas. -Use each washcloth only once before laundering it and avoid bath sponge/puff use. -Avoid sitting on upholstered furniture. -Clean surfaces that may have come into contact with infected pt with household disinfectant or bleach water. -Wash all soiled clothing and linens with hot water and laundry detergent. Dry clothing either in a hot dryer or outside on clothesline in the sun.

CH 25- Chart 25-3: Wound Management of Pressure Injuries

-Rinse and dry the injury area -Remove or trim loose bits of tissue (may be done by certified wound care specialist, PT, advanced practice nurse, or those specified by agency/ state nurse practice act) -Measure wound size using disposable tape measure; for asymmetric injuries, trace wound onto piece of plastic film or sheeting (plastic template) at least weekly or more often if wound shows signs of deterioration -If injury is covered, change dressing: according to manufacturer's instructions when dressing seal is compromised when drainage is visible on outer layer gauze or when dressing becomes contaminated with body fluids.

CH 26- Resuscitation phase of burn injury History Intake -what is significance of dry weight? height determines what and what is that used for? -health hx to note bc can influence fluid resuscitation?

-The pt's preburn weight is used to calculate fluid rates, energy requirements, and drug doses. This weight is the dry weight bc it is the pt's weight before edema forms. Calculations based on a weight obtained after fluid replacement is started are not accurate. Height is impt in determining TBSA, which is used to calculate nutrition needs. -health hx to note: Cardiac or kidney problems Chronic alcoholism Substance abuse DM

CH 25- Chart 25-6 Pt and Family Education on Dry Skin Prevention (p. 462)

-Use room humidifier during winter months or when furnace is in use. -Take bath/shower every other day and wash face, axillae, perineum, and soiled areas with soap daily. -Use tepid water. -Use superfatted, nonalkaline soap instead of deodorant soap. -Rinse soap thoroughly from skin. -If using bath oil, add oil to water at end of bath. -Avoid clothing that rubs against skin such as tight belts, nylon stockings, or pantyhose. -Maintain fluid intake of at least 3,000 mL daily -Do not use rubbing alcohol, astringents, or other drying agents to the skin. -Avoid caffeine and ETOH intake

CH 25- Chart 25-11: Pt and Family Education on Prevention of Skin Cancer

-avoid sun exposure between 11am-3pm -keep a "body map" of your skin spots, scars, and lesions to detect changes -examine body monthly for cancerous or precancerous lesions

CH 25P- Psoriasis -defn? -about what percent of population affected? what ethnicity? -aggravated by? -treatment entails?

A chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate Affects about 2% of the population, primary those of European ancestry Improves and recurs; a lifelong condition May be aggravated by stress, trauma, seasonal and hormonal changes Treatment: baths to remove scales and medications

CH 26- Depth of burn injury Superficial partial thickness burn -defn? appearance? healing time? Deep partial thickness burn -defn? appearance? healing time?

A partial-thickness wound involves tissue integrity loss of the entire epidermis and varying depths of the dermis. Depending on the amt of dermal tissue damaged, partial-thickness wounds are further subdivided into superficial partial-thickness and deep partial-thickness injuries. Superficial partial-thickness wounds are caused by injury to the upper third of the dermis, leaving a good blood supply. These wounds are pink and moist and blanch (lighten) when pressure is applied. The small vessels bringing blood to this area are injured, resulting in the leakage of large amts of plasma, which in turn lifts the heat-destroyed epidermis, causing blister formation. The blisters continue to increase in size after the burn as cell and protein breakdown occur. Small blisters are often left intact if they are not located over a joint. Large blisters usually are opened and debrided to promote healing. Superficial partial-thickness wounds increase pain sensation. Nerve endings are exposed, and any stimulation (touch or temperature change) causes intense pain. With standard care, these burns these burns heal in 10-21 days with no scar; but some minor pigment changes may occur. Deep partial-thickness wounds extend deeper into the skin dermis, and fewer healthy cells remain. Blisters usually do not form bc the dead tissue layer is thick, sticks to the underlying dermis, and does not readily lift off the surface. The wound surface is red and dry with white areas in deeper parts (dry bc fewer bv are patent). When pressure is applied to the burn, it blanches away slowly or not at all. Edema is moderate, and pain is less than superficial burns bc more of the nerve endings have been destroyed. Blood flow to these areas is reduced, and progression to deeper injury can occur from hypoxia and ischemia. Adequate hydration, nutrients, and oxygen are needed for regrowth of skin cells and prevention of conversion to deeper burns. These wounds can convert to full-thickness wounds when tissue damage increases with infection, hypoxia, or ischemia. Deep partial-thickness wounds generally heal in 2-6 weeks, but scar formation results. Surgical intervention with skin grafting can reduce healing time.

SKIP CH 25- Bedbugs

A common parasite is the bedbug, Cimex lectularius. Infestations are increasingly common as a result of travel and resistance to pesticides. This pest does not live on humans; however, it feeds on human blood. The bite causes an itchy discomfort. The most common mode of infestation is carrying the "hitchhiker" bug home from an infested environment such as hotel room. This problem is not related to socioeconomic status or to lack of cleanliness. The adult bedbug is about the size, shape, color of an apple seed. After feeding, it may double in size and have a red or black color. The insect bites a human host at night and sucks blood for 3-10 min. The bite area resembles a mosquito or flea bite with a raised bite mark surrounded by a wheal. The degree of itching and redness is related to how allergic the individual is to the insect's saliva. All body areas are susceptible; and ne insect can bite multiple times, resulting in clusters of bite marks. Management of the pt with bedbug bites is symptomatic for discomfort from itching, usually with topical antihistamines. When the discomfort is more widespread or the allergic reaction is severe, systemic antihistamines or corticosteroids may be used. Bc humans do not harbor the insect, the usual topical insecticides are not needed. Bedbugs can live anywhere, hiding in cracks and crevices. They can live and lay their eggs in soft upholstery or in wooden crevices. Eradicating the infestation and preventing re-infestations require considerable effort and can be frustrating. Often the home environment needs extensive eradication efforts of licensed pest-control company with experience in management of bedbugs.

CH 26- Depth of burn injury Full-thickness wound -defn? appearance? sensation? healing time?

A full-thickness wound occurs with destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. This wound does not regrow, and areas not closed by wound contraction require grafting. The full-thickness urn has a hard, leathery eschar that forms from coagulated particles of destroyed skin. The eschar is dead tissue; it must slough off or be removed from the wound before healing can occur. These thick particles often stick to the lower tissue layers, making eschar removal difficult. Edema is severe under the eschar in a full-thickness wound. When the injury is circumferential (completely surrounds an extremity or the chst), blood flow and chest movement for breathing may be reduced by tight eschar. Escharotomies (incisions through the eschar) or fasciotomies (incisions through eschar and fascia) may be needed to relieve pressure and allow normal blood flow and breathing. A full-thickness burn may be waxy white, deep red, yellow brown, or black. Thrombosed and heat-coagulated blood vessels may be seen beneath the surface of the burn and leave the burned tissue without a blood supply. Sensation is reduced or absent bc of nerve-ending destruction. Healing time depends on establishing a good blood supply in the injured areas. This process can range from weeks to months.

CH 26P- Burns

Approximately 450,000 people require medical attention of burns every year, and about 14 % of them die from burns and associated inhalation injuries every year. Most burns occur in the home. Young children and the older adults are at high risk for burn injuries. Nurses must play an active role in the prevention of burn injuries by education regarding prevention concepts and promoting safety

CH 25- Pressure injury pathophys -how do pressure injuries arise (pathophys)? -what complications can arise from pressure injuries?

A pressure injury (PrI) is 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. Although they commonly occur over the sacrum, hips, and ankles, pressure injuries can occur on any body surface. For ex, nasal cannula tubing that is too tight can cause pressure injuries behind the ears or in the nares. Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and gas exchange, which eventually leads to cell death. Ulcers occur most often in adults with limited mobility bc the cannot change their position to relieve pressure. Pts who cannot feel or communicate the pain that occurs with unrelieved pressure are more likely to develop pressure injuries. Once formed, these chronic wounds are slow to heal, resulting in increased mobility and health care costs. Complications include sepsis, kidney failure, infectious arthritis, and osteomyelitis. Friction and shear are mechanical forces that impair skin tissue integrity and cause skin tears, which set the stage for skin breakdown. Excessive skin moisture, such as urinary or fecal incontinence, also increases the risk for skin damage. Nutrition status is an impt concern. Protein malnutrition makes normal tissue more prone to breakdown and also delays healing.

CH 26- Metabolic Changes associated with burns -burns will decrease or increase metabolism? resulting in elevated needs for? -elevated temp (fever) or lower body temp?

A serious burn injury greatly increases metabolism by increasing secretion of catecholamines, antidiuretic hormone, aldosterone, and cortisol. With this hypermetabolism, the pt's oxygen use and calorie needs are high. The catecholamines activate the stress response. The increased production (and loss) of heat break down protein and fat (catabolism), rapidly use glucose and calories, and increase urine nitrogen loss. The heat and water lost from the burn also increase metabolic rate and calorie needs. Depending on extent of injury, the pt's calorie needs double or triple normal energy needs. These increased rates peak 4-12 days after the burn and can remain elevated for months until all wounds are closed. The hypermetabolic condition also increases core body temperature. The pt loses heat through the burned areas. Core body temperature increases as a response to the adjustment in temp regulation by the hypothalamus, resulting in a low-grade fever. Effect on thermoregulation

CH 25 Skin cancer etiology and genetic risk -what are actinic (solar) keratoses? -squamous cell carcinoma is cancer of? what factor predisposes to malignancy? -metastasis risk for basal cell carcinoma? -melanomas start as? metastasis risk for melanomas?

Actinic (solar) keratoses are premalignant lesions of the cells of the epidermis. These lesions are common in adults with chronically sun-damaged skin. Progression to squamous cell carcinoma may occur if lesions are untreated. Squamous cell carcinomas are cancers of the epidermis. They can invade locally and are potentially metastatic. Chronic skin damage from repeated injury or irritation also predisposes to this malignancy. Chronic wounds that remain open for long periods are also at increased risk for malignant transformation to cancer. Basal cell carcinomas arise from the basal cell layer of the epidermis. Early lesions often go unnoticed; and, although metastasis is rare, underlying tissue destruction can occur. Genetic predisposition and chronic irritation are risk factors; however, UV exposure is the most common cause. Melanomas are pigmented cancers arising in the melanin-producing epidermal cells. Most often they start as the benign growth of a nevus (mole). Normal nevi have regular, well-defined borders and are uniform in color, ranging, from light colors to dark brown. The lesion's surface may be rough and smooth. Nevi with irregular or spreading borders and those with multiple colors are abnormal. Other suspicious features include sudden changes in lesion size and reports of itching or bleeding. Risk factors include genetic predisposition, excessive exposure to UV light, and the presence of one or more precursor lesions that resemble unusual moles. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment.

CH 26- Compensatory changes associated with burns -burns interrupt homeostasis, this will cause body to use what two compensatory responses?

Any injury is a stressor and can disrupt homeostasis. Two compensatory (adaptive) responses have immediate benefit: the inflammatory response and the sympathetic nervous system stress response. Together these tresponse cause changes that result in many signs of the signs and sx seen in first 2-3 days after a burn injury. Inflammatory compensation is helpful by triggering healing in the injured tissues and also is responsible for the serious problems that occur with the fluid shift. This compensation causes bv to leak fluid in the interstitial space and WBCs to release chemicals that trigger local tissue reactions. These responses cause the massive fluid shift, edema, and hypovolemia that are seen in the resuscitation phase (first 24-48 hr) after a burn injury. The extent of the inflammatory response depends on the burn severity. Sympathetic nervous system compensation is the stress response that occurs when any physical stressors are present. Changes caused by the sympathetic nervous system are most evident in the cardiovascular, respiratory and GI systems.

CH 25- Skin Cancer pathophys -three most common skin cancers?

Any skin cancer occurs as a result of failure of cellular regulation over cell division. Overexposure to sunlight is the major cause of skin cancer, although other factors are associated. Bc sun damage is an age-related skin finding, screening for suspicious lesions is an important part of physical assessment of the older adult. The most common precancerous lesions are actinic (solar) keratosis, and the most common skin cancers are squamous cell carcinoma, basal cell carcinoma, and melanoma. A bx of suspicious lesions is necessary to determine whether a skin lesion is malignant.

CH 26- Chart 26-1: Emergency Management of Burns (p. 489)

Assess for airway patency Administer oxygen as needed Cover pt with blanket Keep pt NPO Elevate extremities if no fx present Start IV and begin fluid recesitation Administer tetanus prophylaxis Perform head to toe Obtain vitals

CH 24- Features associated with skin cancer?

Asymmetry of shape Border irregularity Color variation within one lesion Diameter greater than 6 mm Evolving or changing of any feature (shape, size, color, elevation, itching, bleeding, or crusting)

CH 25P- Stevens-Johnson Syndrome Complications -name 4 potential complications?

Sepsis Conjunctival retraction, scars, and corneal lesions

CH 25- Bacterial Skin Infection -what is impetigo? -folliculitis vs furuncles vs carbuncles?

Bacterial skin lesions usually start at the hair follicle, where bacteria easily collect and grow in the warm, moist environment. Folliculitis is a superficial infection involving only the upper part of the follicle and is often caused by Staphylococcus. The rash is raised and red and usually shows small pustules. Furuncles (boils) are also caused by Staphylococcus but the infection is much deeper in the follicle. The larger, inflamed, raised bump may or may not have a pustular "head" at its point. Cellulitis often occurs as a generalized infection with either Staphylococcus or Streptococcus and involves the deeper connective tissue. Minor skin trauma usually occurs before the appearance of folliculitis and furuncles and may contribute to the development of cellulitis. Pts may spread the infection to other parts of their bodies by scratching or rubbing the skin. Furuncles most often occur in areas of heat and moisture, such as in the hair-bearing skinfold areas. Cellulitis can occur as a result of secondary bacterial infection of an open wound, or it may be unrelated to skin trauma. A common skin problem is infection with MRSA. This infection can range from mild folliculitis to extensive furuncles. It is easily spread to other body areas and to other people by direct contact with infected skin and by contact with clothing, linens, athletic equipment and other objects used by the person with MRSA. The infection does not respond to cleansing with antibacterial soaps or most types of topical and many oral abx therapies. If MRSA infects a wound or enters the bloodstream, deep wound infection, sepsis, organ damage, and death can occur. The incidence is highest among adults living in communal environments such as dorms or prison, and among pts in hospitals and other healthcare settings. Cutaneous anthrax is an infection caused by the spread of spores the bacterium Bacillus anthracis. In the US, the most common risk factor is contact with an infected animal. Those most at risk for cutaneous anthrax include farm workers, vets, and tannery and wool workers. This organism has now become a tool for terrorism. NURSING SAFETY PRIORITY- Action Alert: Consider the possibility of bioterrorism whenever lesions consistent with cutaneous anthrax in pts who do not have a hx of exposure to infected animals. The infection can be confined to the skin, or it may be systemic. At first, a raised vesicle appears on an exposed body area such as head or arm. The lesion may itch and often resembles an insect bite. Within a few days, the center of the vesicle becomes hemorrhagic and sinks inward, starting an area of necrosis and ulceration. The tissue around the wound swells and can become very edematous. With necrosis, an eschar forms. The two features that distinguish anthrax lesions from insect bites or other skin lesions are that is painless and that eschar forms, regardless of treatment. Pts may have only one lesion, or there may be multiple lesions, usually in the same body area. Some pts develop systemic sx with cutaneous anthrax. The area becomes edematous and tender. Fever, chills, and enlarged lymph nodes may be present. Dx is made based on lesion features, a positive culture, or the presence of anthrax antibodies in the pt's blood. Cultures are obtained from pts who have a fever. Oral abx for 60 days are indicated for pts who have no edema or systemic sx and whose lesions are not located on the head or neck. The abx of choice are Cipro or doxycycline (Doryx, Biramycine). For pts who have a fever, have lesions on head or neck, are pregnant, or have extensive edema, abx are given IV and then followed by oral abx.

CH 26- Etiology of Burns Describe each of the burns: -dry heat burn -moist heat injury -contact burns -chemical burns -electrical burns -thermal burn -conductive electrical injury -radiation burn

Burn injuries are caused by dry heat (flame), moist heat (scald), contact with hot or rough surfaces, chemicals, electricity, and ionizing radiation. The cause of the injury affects both the prognosis and the treatment. Dry heat injuries are caused by open flame in house fires and explosions. Explosions usually result in flash burns bc they produce a brief exposure to very high temperatures. Moist heat (scald) injuries are caused by contact with hot liquids or steam. Scald injuries are more common among older adults than younger adults. Hot liquid spills usually bun the upper, front areas of the body. Immersion scald injuries usually involve the lower body. Contact burns occur when hot metal, tar, or grese contacts the skin, often leading to a full-thickness injury. Hot metal injuries occur when a body part contacts a hot surface, such as a space heater, or iron. They also can occur in industrial settings from molten metals. Tar and asphalt temperatures usually are greater than 400F, and deep injuries occur within sec when the skin is immersed in or splashed with them. Hot grease injuries from cooking are usually deep bc of the high temperature of the grease. Chemical burns occur in home or industrial accidents or as the result of assault. Injury occurs when chemicals directly contact the skin and epithelial tissues or are ingested. The severity of the injury depends on the duration of contact, the concentration of the chemical, the amt of tissue exposed, and the action of the chemical. Alkalis found in oven cleaners, fertilizers, drain cleaners, and heavy industrial cleaners damage the tissues by causing the skin and its proteins to liquefy. This allows for deeper spread of the chemical and more severe burns. Acids found in bathroom cleaners, rust removers, pool chemicals, and industrial drain cleaners damage tissue integrity by coagulating cells and skin proteins, which can limit the depth of tissue damage. Chemical disinfectants and gasoline are easily absorbed through the skin and have toxic effects on the kidney and liver. Electrical injuries are burns occurring when an electrical current enters the body. These injuries have been called the "grand masquerader" of burns bc the surface injuries look small but the associated internal injuries can be huge. Tissue injury from electrical trauma results from electrical energy being converted to heat energy. The extent of injury depends on the type of current, the pathway of flow, local tissue resistance, and duration of contact. Once the current penetrates the skin, it flows through the involved body part, generating heat and damaging tissues. Deep muscle injury may be present when the superficial muscles appear normal or uninjured. The longer the electricity is in contact with the body, the greater the damage. The duration of contact is increased by tetanic contractions of the strong flexor muscles in the forearm, which can prevent the person from releasing the electrical source. It is difficult to know the exact path a current takes in the body. The course of flow is defined by the locations of the "contact sites," which are the entrance and exit wounds. At first, the wounds may not be obvious. The path of injury may involve many internal organs between the two contact sites. Burn injuries from electricity can occur as thermal burns, flash burns or true electricity injury. Thermal burns occur when clothes ignite from heat or flames produced by electrical sparks. External burn injuries can occur when the electrical current jumps, or "arches" between two body surfaces. These injuries are usually severe and deep. True electrical injury occurs when direct contact is made with an electrical source. Internal damage results and can be devastating. Damage starts on the inside and goes out; deep-tissue destruction may not be apparent immediately after injury. Organs in the path of the current may become ischemic and necrotic. Radiation injuries occur when people are exposed to large doses of radioactive material. The most common type of tissue injury from radiation exposure occurs with therapeutic radiation. This injury is usually minor and rarely causes extensive skin damage. Radiation exposure is more serious in industrial settings where radioactive energy is produced or used. Injury severity depends on the type of radiation, distance from the source, duration of exposure, absorbed dose, and depth of penetration into the body.

SKIP CH 26- Immunologic changes associated with burns

Burn injury disrupts or destroys the protective skin tissue integrity, increasing the risk for infection. The injury activates the inflammatory response and often suppresses all types of immune functions. Abx therapy and other interventions for burns further reduce immune fxn.

CH 26P- Physiologic changes from burns -burns < __% --> local response -burns > __% --> local response and systemic response

Burns less than 25% TBSA (total body surface area) produce primarily a local response. Burns more than 25% may produce a local and systemic response and are considered major burns. Systemic response includes release of cytokines and other mediators into systemic circulation. Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction.

CH 25P- What is candida albicans?

Candida albicans fungal infection of the mouth (thrush).

CH 25- Pruritus interprofessional collab care -what does scratching do to itch receptors? -what systemic diseases can cause itching without skin lesions (2)? one of which causes a buildup of?

Care of the pt with minor skin irritations usually takes place in the outpatient setting. Members of the interprofessional team who collaborate most closely to care for this pt include PCP, who continually assess the skin condition and prescribes treatment, and the RN. The priority nursing interventions focus on increasing pt comfort and preventing skin injury with loss of tissue integrity. Pts usually try to relieve itching by scratching or rubbing the skin, a response that further stimulates the itch receptors and causes the "itch-scratch-itch" cycle. Itching with skin lesions can often be relieved by treating the underlying skin disorder with topical or systemic drugs. Systemic diseases, such as liver and venous disorders, can also cause itching without skin lesions. Liver disease often increases the buildup of bilirubin in the skin, which stimulates itch receptors. Pruritus can also be caused by too little or too much blood flow to an area especially the feet and legs). Plan care to promote comfort and prevent disruption of skin tissue integrity from vigorous scratching. Bc dry skin worsens itching, emphasize interventions to prevent it. Encourage pts to keep the fingernails trimmed short, with rough edges filed to reduce damage from scratching and secondary infection. Wearing mittens or splints at night can help prevent scratching during the sleep. If the pt cannot perform self-care, teach family and UAP to trim the pt's fingernails and apply mittens or gloves. Stress the importance of not breaking skin or digging into nail corners when trimming the nails of pts with DM. A cool sleeping environment and comfort measures (ex cool shower, moisturizers) may help promote sleep. Using sleep-promoting herbal teas or sedating antihistamines at bedtime (when the side effect of drowsiness is welcome) may provide an uninterrupted night's sleep for some pts. Colloidal oatmeal or tar extract baths provide temporary relief. If antihistamines are prescribed, monitor pt's response so the dosage can be adjusted as needed. The effectiveness of topical steroid preparations and other topical agents is improved if the drug is applied to slightly damp skin. Using topical drugs under an occlusive dressing increases the dose being delivered. Avoid occluding treated areas unless specifically prescribed by PCP.

REVIEW CH 26- Vascular changes associated with burns

Circulation to the burned skin is disrupted immediately after injury by bv occlusion. Macrophages in damaged tissues release chemicals that at first cause bv constriction. Bv thrombosis may occur, causing necrosis, which can lead to deeper injuries in these areas. Fluid shift occurs after initial vasoconstriction as a result of bv near the burn dilating and leaking fluids into the interstitial space. Theis fluid shift, also known as third spacing or capillary leak syndrome, is a continuous leak of plasma from the vascular space into the interstitial space. The impaired fluid and electrolyte balance leads to loss of plasma fluids and proteins, which decreases blood vol and blood pressure. Leakage of fluid and electrolytes from the vascular space continues, causing extensive edema, even in areas that were not burned. Fluid shift, with excessive weight gain occurs in the first 12 hr after the burn and can continue for 24-36 hrs. The amt of fluid shifted depends on the extent and severity of injury, capillary leak occurs in both burned and unburned areas when tissue damage is extensive (i.e. more than 25% total body surface area). Edema develops as plasma and electrolytes escape into the interstitial space. The proteins now in the interstitial space increase the movement of fluids out from the vascular space. Profound disruptions of fluid and electrolyte balance and acid-base balance occur as a result of the fluid shift and cell damage. These imbalances often include hypovolemia, metabolic acidosis, hyperkalemia (high blood K level), and hyponatremia (low blood Na level). Hyperkalemia occurs as a result of direct cell injury that releases large amts of cellular potassium. Sodium is retained by the body as a result of the endocrine response to stress. Aldosterone secretion increases, leading to increased sodium reabsorption by the kidney. However, this na quickly apsses into the interstitial spaces of the burned area with the fluid shift. Thus, despite the increased amt of na in the body, most of the Na is trapped in the interstitial space, and a Na deficit occurs in the blood. Hemoconcentration (elevated blood osmolarity, hematocrit, and hemoglobin) develops from vascular dehydration. This problem increases blood viscosity, reducing blood flow nand and increasing tissue hypoxia. Fluid remobilization starts at about 24 hrs after injury, when the capillary leak stops. The diuretic stage begins at about 48-72 hrs after the burn injury as capillary membrane integrity returns and edema fluid shifts from the interstitial spaces into the intravascular space. Blood vol increases, leading to increased kidney blood flow and diuresis unless kidney damage has occurred. Body weight returns to normal over the next few days as edema subsides. During this phase, hyponatremia develops bc of increased kidney sodium excretion and the loss of Na from wounds. Hypokalemia (low blood K level) results from potassium moving back into the cells and also being excreted in urine. Anemia often develops as a result of hemodilution, but it is generally not severe enough to require blood transfusion.s transfusions are needed only if the pt's HCT is < 20-25% and the pt has signs and sx of hypoxia. Protein continues to be lost from the wounds. Metabolic acidosis is possible bc of the loss of bicarbonate in the urine and the increased rate of metabolism.

CH 25- Pressure Injury Consideration for Older Adults -three considerations to take into account that increase PrI risk?

Consideration for Older Adults: Older adults are at higher risk for skin tears and pressure injuries bc of age-related skin changes. Flattening of cells at the dermal epidermal junction predisposes older adults to skin tears from mechanical shearing forces such as tape removal and minor trauma. Skin moisture and irritation from incontinence combined with friction over bony prominences can lead to skin destruction with loss of tissue integrity and pressure injury formation. Pts with cognitive impairment may not readily report discomfort from inadequate pressure relief. If pressure is unrelieved, tissue destruction progresses to full-thickness ulcer. Assess pts with cognitive impairments more frequently for loss of skin tissue integrity.

CH 24- Dark skin considerations for cyanosis and jaundice -where are gray areas indicating cyanosis? -where to assess jaundice?

Cyanosis For darker skin pts: Cyanosis can be present when gas exchange is impaired. Examine the lips, tongue, nail beds, conjunctivae, and palms and soles for subtle color changes. In a pt with cyanosis, the lips, and tongue are gray; and the palms, soles, conjunctivae, and nail beds have a bluish tinge. To support these findings, assess for other indicators of hypoxia, including tachycardia, hypotension, changes in RR, decreased breath sounds, and changes in cognition. Jaundice For darker skin pts: Jaundice in a pt with dark skin is best assessed by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Yellowness of the conjunctivae and adjacent sclera may be misleading bc normal deposits of fat produce a yellowish hue that is visible in contrast to the dark skin around the eyes. Examine the sclera closest to the cornea for a more accurate determination of jaundice. The palms and soles of dark-skinned pts may appear yellow if they are calloused, even when jaundice is not present.

CH 26- Depth of burn injury Deep full-thickness wound -defn? appearance? healing time?

Deep full-thickness wounds extend beyond the skin and damage muscle, bone, and tendons. These burns occur with flame, electrical, or chemical injuries. The wound is blackened and depressed, and sensation is completely absent. All full-thickness burns need early excision and grafting. Grafting decreases pain and length of stay and hastens recovery. Amputations may be needed when an extremity is involved.

REVIEW CH 25- Fungal Skin Infection

Dermatophyte infections, especially superficial infections, differ in lesion appearance, body location, and species of the organism. The term tinea is used to describe dermatophytoses; this term is then followed by the location description. For ex, tinea pedis involves the foot (athlete's foot), tinea manus involves the hands, tinea cruris involves the groin (jock itch), tinea capitis involves the head, and tinea corporis involves the rest of the body (ringworm). Depending on the species, dermatophytes live mainly in the soil, on animals, and on human. Superficial infection can start only when the infecting organism comes in contact with impaired skin in a susceptible host. Infections are spread by direct contact with infected humans or animals. Some infections, such as tinea capitis and tinea corporis, can be transmitted by inanimate objects. For ex, tinea capitis can be spread by sharing contaminated combs, hats, pillowcases, and other objects with individuals with poor personal hygiene. Candida albicans, also known as yeast infection, is a common fungal infection of skin and MM. the organism is present almost everywhere and easily grows in a warm, moist environment. Risk factors for this infection, include immunosuppression, long-term abx therapy, DM, and obesity. Infected skin has a moist, red, irritated appearance with itching and burning. Common areas for infection are the perineum, vagina, axillae, under the breasts, and in the mouth (where it is known as thrush or oral candidiasis). Prevention is aimed at keeping skinfold areas clean and dry. Turning pts and positioning to enhance airflow also aid in prevention. When the infection is present, meticulous cleanliness and the use of topical antifungal agents are needed.

REVIEW CH 26- Pulmonary changes associated with burns -3 ways to get airway edema? -effect of smoking on airway?

Direct injury to the lungs from contact with flames rarely occurs. Rather, respiratory problems are caused by superheated air, steam, toxic fumes, or smoke. Such problems are a major cause of death in pts with burns and are most likely to occur when the burn takes place indoors. Respiratory failure with burn injuries can result from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns that restrict chest movement, and carbon monoxide poisoning. Respiratory damage from an inhalation injury can occur in the upper and major airways and the lung tissue. The upper airway is affected when inhaled smoke or irritants cause edema and obstruct the trachea. Heat can reach the upper airway, causing an inflammatory response that leads to edema of the mouth and throat with the potential of airway obstruction. Chemicals and toxic gases produced during combustion can cause airway injury. The ciliated membranes lining the trachea normally trap foreign materials. Smoke and gases slow this activity, allowing particles to enter the bronchi. The lining of the trachea and bronchi may slough 48-72 hrs after injury and obstruct the lower airways. Lung tissue injuries result from toxic irritant damage to the alveoli and capillaries. Leaking capillaries cause alveolar edema, which can occur immediately or up to a week after the injury. The fluid that diffuses into the lung tissue spaces contains proteins that form fibrinous membranes and lead to respiratory distress. Progressive pulmonary failure develops, leading to acute pulmonary insufficiency and infection.

SKIP CH 25- Nonsurgical management of skin cancer

Drug therapy may involve topical or systemic chemotherapy, biotherapy, or targeted therapy. Topical chemotherapy with 5-fluorouracil cream is used for treatment of multiple actinic keratoses or for widespread superficial basal cell carcinoma that would require several surgical procedures to eradicate. Therapy is continued for several weeks; and the treated areas become increasingly tender and inflamed as the lesions crust, ooze, and erode. Prepare the p for an unsightly appearance during therapy and reassure pt that the cosmetic result will be positive. Imiquimod (Aldara) is a new topical treatment option for superficial basal cell carcinoma. This type of therapy stimulates the immune system to produce interferon, a chemical that attacks cancer cells. Several systemic agents are indicated for treatment of locally advanced or metastatic squamous cell skin cancer. These include a platinum based-agent (Cisplatin or Carboplatin), 5-fluorouracil, and cetuximab (Erbitux) for advanced squamous cell carcinoma. Oral drugs approved for advanced basal cell carcinoma include vismodegib (Erivedge) and sonidegib (Odomzo). Biotherapy with interferon, monoclonal antibodies, and targeted therapy are now accepted treatment for melanoma after surgical removal. Interferon is used for melanomas that are at stage 3 or higher. The pt is first started on high-dose IV interferon infusions daily for 5 days per week for 4 weeks. Maintenance doses, given subcutaneously, are then continued three times per week for 1 yr. The pt must learn to self-inject the drug. Monoclonal antibody therapy with ipilimumab (Yervoy), a drug that targets the CTLA4 (cytotoxic T-lymphocyte associated antigen 4) receptor and blocks it, leads to greater T-cell lymphocyte activity. (T-cells are a type of lymphocyte that can stimulate antitumor immune responses). The side effects of this drug include significant inflammation in many tissues, including the pituitary gland, liver, skin, GI tract, and nervous system. Some of these side effects are life threatening. Targeted therapy is available for melanomas with specific mutations in the BRAF gene. Normally the BRAF gene is involved in cellular regulation of growth. Mutations in this gene allow melanoma to grow and metastasize. When melanoma cells are positive for a specific BRAF mutation (V006E), the cells respond to the drug vemurafenib (Zelboraf). The drug inhibits an enzyme important in signaling cell division and prevents melanoma cell division. This oral drug interacts with a variety of other drugs, and allergic reactions are common. Radiation therapy for skin cancer is limited to older patients with large, deeply invasive basal cell tumors and to those who are poor risks for surgery. Melanoma is relatively resistant to radiation therapy. Immune check inhibitors stimulate the immune system to recognize and destroy cancer cells more effectively. Pembrolizumab (Keytruda) and nivolumab (Opdivo) target a protein on the surface of T-cells (PD-1). Blocking PD-1 increases T-cell activation, which helps the body attack melanoma cells but can also stimulate the immune system to attack non cancerous tissue. To avoid serious side effects, teach pts to report any new sx to the healthcare team asap.

CH 26P- Phases of Burn Injury

Emergent or resuscitative phase: Onset of injury to completion of fluid resuscitation Acute or intermediate phase: From beginning of diuresis to wound closure Rehabilitation phase: From wound closure to return to optimal physical and psychosocial adjustment

CH 24- Describe the three skin layers: Epidermis -how is it attached to dermis? epidermis size? -does it have a blood supply? how does it receive nutrients? -keratinocytes involvement? Dermis -aka? contains? composed of and role? -dermis has what that involves exchange of oxygen and heat? -rich in what? Subcutaneous fat-aka? -lies over? subcutaneous fat role? -what goes through the fatty layer and extends to dermis?

Epidermis is the outermost skin layer. It is anchored to the dermis by fingerlike projections (rete pegs) that interlock with dermal structures called dermal papillae. Less than 1 mm thick, the epidermal layer is the first line of defense between the body and environment. The epidermis does not have its own blood supply. Instead it receives nutrients by diffusion from the blood vessels in the dermal layer. Attached to the basement membrane of the epidermis are the basal keratinocytes--skin cells that undergo cell division and differentiation to continuously renew skin tissue integrity and maintain optimal barrier function. As basal cells divide, keratinocytes are pushed upward and form the spinous layer (stratum spinosum). Together the basal layer and the spinous layer are referred to as the germinative layer (stratum germinativum) bc these layers are responsible for new skin growth. The keratinocytes continue to enlarge and flatten as they move upward to form the outermost horny skin layer (stratum corneum). When these cells reach the stratum corneum (in 28-45 days), they are no longer living cells and are shed from the skin surface. Keratin, a protein produced by keratinocytes, makes the horny layer waterproof. Dermis (corium) is the layer above the fat layer and contains no skin cells but does contain some protective mast cells and macrophages. The dermis is composed of interwoven collagen and elastic fibers that give the skin flexibility and strength. The dermis has capillaries and lymph vessels for exchange of oxygen and heat. It is rich in sensory nerves that transmit the sensations of touch, pressure, temp, pain, and itch Subcutaneous tissue (fat) (aka adipose tissue/fat) is the innermost layer of the skin, lying over muscle and bone. Fat distribution varies with body area, age, and gender. Fat cells insulate the body and absorb shock, pradding internal structures. Bv go through the fatty layer and extend into the dermis, forming capillary networks that supply nutrients and remove wastes.

REVIEW CH 25- Pressure-redistribution technique Positioning

Frequent repositioning of bedbund pts is critical in reducing pressure over bony prominences. A good plan for positioning is the 30-degree rule. This plan ensures that the pt is positioned and propped so whatever part of the body is elevated is tilted back to no more than a 30 degree angle to the mattress rather than resting directly on a dependent bony prominence. This rule applies to side-lying and head-of-bed elevation bc of respiratory difficulties should be tilted up above 30 degrees will pillows behind the back to keep pressure off of the sacral/coccyx area. Often positioning is delegated to UAP. Teach UAP the importance of proper positioning, demonstrate how to perform it, and provide appropriate supervision. Also teach family members to use these techniques in the home. The pt at risk for pressure injuries in bed is also at risk while sitting. Assess for proper chair cushioning. Collaborate with physical therapists and rehabilitation specialists for selection of these products. Periodically assist high-risk pts who are chair bound to a standing position to promote perfusion and prevent breakdown over the sacral area. Even with an appropriate mattress or cushion, the pt needs to change or be helped to change positions periodically to prevent loss of skin tissue integrity. Many facilities require turning and repositioning every 2 hrs. However, pressure can occur in less time, and the actual turning or repositioning schedule for each pt must be individualized. When this action is delegated to UAP teach them the importance of maintaining a repositioning schedule and supervise appropriately. Use pillows and other positioning or heel-suspension devices to keep heels pressure free at all times for high-risk pts. Assess heel positioning every 4 hrs to ensure that pressure is not redistributed to other high-risk areas, such as the ankles or side of the feet. Check heels even more often when devices that hide the feet (ex boots, heel protectors) are used, especially if the pt has a vascular problem. Also check knees and elbows regularly, especially when the pt is in a side-lying position.

CH 25P- Skin cancer -Why is basal cell carcinoma most successfully treated? which one involves mets?

Frequently related to sun exposure—prevention: use of sunscreen and avoid sun exposure Incidence is increasing Prevention of all types of skin cancer involves protection from excessive sun exposure Basal cell carcinoma Most common type and most successfully treated because tumors remain localized Squamous cell carcinoma Prognosis depends upon presence of metastasis Treatment involves eradication of the tumor

REVIEW CH 26- Cardiac changes associated with burns

HR increases and CO decreases bc of the initial fluid shifts and hypovolemia that occur after a burn injury. CO may remain low until 18-36 hrs after the burn injury. It improves with fluid resuscitation and reaches normal levels before plasma vol is restored completely. Proper fluid resuscitation and support with oxygen prevent further complications.

CH 24- Skin Appendages

Hair follicles are located in the dermal layer of the skin but are actually extensions of the epidermal layer. Within each hair follicle, a round column of keratin forms the hair shaft. Hair color is genetically determined by an individual's rate of melanin production. Hair growth occurs in cycles of a growth phase followed by a resting phase. Growth is dependent on a good blood supply and adequate nutrition. Stressors can alter the growth cycle and result in temporary hair loss. Permanent baldness, such as male pattern baldness, is inherited. Nails protect and enhance sensation of the fingertips and toe tips., have cosmetic value, and are useful for grasping and scraping. Like hair follicles, the nails are extensions of the keratin-producing epidermal layers of the skin. The white, crescent-shaped part of the nail at the lower end of the nail plate is the lanula and is where nail keratin is formed and nail growth begins. Nail growth is a continuous but slow process. Fingernail replacement requires 3-4 months. Toenail replacement may take up to 12 months. The cuticle attaches the nail plate to the soft tissue of the nail fold. The nail body is translucent, and the pinkish hue reflects a rich blood supply beneath the nail surface. Nail growth and appearance are often altered during systemic disease or serious illness. Sebaceous glands are distributed over the entire skin surface except for the palms of the hands and soles of the feet. Most of these glands are connected directly to the hair follicles. Sebaceous glands produce sebum, a mildly bacteriostatic, fat-containing substance. Sebum lubricates the skin and reduces water loss from the skin surface. Sweat glands of the skin are of two types: eccrine and apocrine. Eccrine sweat glands arise from the epithelial cells. They are found over the entire skin surface (except lips) and are not associated with the hair follicle. The odorless, colorless secretions of these glands are important in body temperature regulation. This sweat and the resultant water evaporation can cause the body to lose up to 10-12L of fluid in a single day. Composed of salts, ammonia, urea, and other wastes. Apocrine sweat glands are in direct contact with the hair follicle and are found mostly in the axillae, nipple, umbilical, and perineal body areas. The interaction of skin bacteria with the secretions of these glands causes body odor. Secrete thick milky substance that becomes odoriferous when altered by skin surface bacteria

CH 25P- Parasitic Disorder Pediculosis

Head lice may infest anyone and are not a sign of uncleanliness. Instruction in use of shampoo (lindane [Kwell] or pyrethrin [RID]) and combing of hair with fine-tooth comb dipped in vinegar to remove all nits Note lindane may have toxic effects and must be used only as directed. All articles of clothing and bedding must be disinfected, washed in hot water, or dry cleaned. Furniture and floors should be frequently vacuumed. Do not share combs, hats, and so on. All family members and close contacts must be treated.

CH 25- Viral Skin Infection -which is the most common viral infection? describe each of the two strains? recurrence of this viral infection is triggered by stressors such as (6)? -what is herpes zoster? infection caused by? what is common in older adults? contagious to whom? isolate pts until?

Herpes Simplex virus (HSV) infection is the most common viral infection of adult skin and has two types. Type 1 (HSV-1) infections cause the classic recurring cold sore. The severity of the disease increases with age and is worse when the pt is immunosuppressed. Genital herpes, caused by type 2 infection (HSV-2) is also recurrent. After the first infection, the virus remains in a dormant state in the nerve ganglia, and the pt has no sx. Reactivation stimulates the virus to travel down sensory nerves to the skin, where lesions reappear. Recurrence of HSV infection healthy people is triggered by stressors, such as dry lips, sunburn, trauma, fever, menses, and fatigue. The virus als can be spread by contact between an actively infected person and a susceptible host. Autoinoculation, or transfer of either viral type from one part of the body to another, is also possible. The time span between episodes and the sensitivity of each attack vary. Outbreaks of oral herpes simplex usually last 3-10 days. The pt mau have tingling or burning of the lip before any lesion is evident. The pt sheds virus and is contagious for the first 3-5 days. The clinical picture of HSV-1 infection is isolated or grouped painful vesicles on a red base. The infection can occur anywhere on the skin and may be spread by respiratory droplets or direct contact with an active lesion or virus-containing fluid (ex saliva). Herpetic whitlow is a form of HSV that occurs on the fingertips of health care personnel wh come into contact with viral secretions. It can be spread easily to pts and can become severe in immunosuppressed pts. Herpes zoster (shingles) is infection caused by reactivation of the varicella-zoster virus (VZV) in pts who have previously had chickenpox. The dormant virus resides in the dorsal root ganglia of sensory nerves. Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve. Herpes zoster eruptions usually occur after several days of discomfort, which may vary from minor irritation and itching to severe, deep pain. The eruption usually lasts several weeks. Postherpetic neuralgia (severe pain persisting after the lesions have resolved) is common in older pts. Early diagnosis of shingles and prompt treatment with antiviral drugs help decrease the duration and severity of postherpetic neuralgia. Herpes zoster occurs most often in older adults or in anyone who is immunosuppressed. The disorder can be accompanied by fever and malaise. It is contagious to people who have not previously had chickenpox and have not been vaccinated against the disease. Reduce the risk of viral transmission by isolating pts with fluid-filled blisters and vesicles until the lesions have crusted over and are dry. Complications include full-thickness skin necrosis, Bell's palsy, or eye infection, and scarring if the virus is introduced into the eye.

CH 25P- Herpes Zoster viral infection

Herpes zoster: instruction regarding prescribed antiviral medications, lesion care, dressings, and hand hygiene Herpes simplex: instruction regarding prescribed antiviral medications and prophylactic medication use, instruction regarding spread of herpes, and measures to reduce contagion of partner or of neonates born to mothers with genital herpes

REVIEW CH 25- Hx Intake for Skin Infection Pt

History Concentrate on risk factors for each type of infection. If the location and appearance of lesions suggest a bacterial staphylococcal or streptococcal infections. Assess living conditions, home sanitation, personal hygiene habits, and leisure or sport activities. Ask whether fever and malaise are also present. Lesions appearing on the lips, in the mouth, or in the genital region are more likely to be a possible viral infection. Ask about: A hx of similar lesions in the same location Presence of burning, tingling, or pain Recent stress factors that preceded the outbreak Recent contract with an infected person Information about the same type of lesions has occurred before is impt in helping differentiate viral from bacterial lesions. Ask whether the pt has had chickenpox in the past and about hx of shingles. Also ask whether pt has received shingles vaccination Zostavax. Obtain information about a probable dermatophyte infection based on lesion location. If tinea corporis or tinea capitis is present, assess the social and home factors that may contribute to infection, such as direct contact with an infected person, poor personal hygiene, or frequent contact with animals. If tinea cruris and tinea pedis are suspected, ask about the type and frequency of athletic activities.

CH 26P- Factors when assessing burns

How the injury occurred Causative agent Temperature of agent Duration of contact with the agent Thickness of the skin

CH 24- Secondary Skin Lesions

Secondary lesions evolve from primary lesions or develop as a consequence of the pt's activities. These changes occur with progression of an underlying disease or in response to topical or systemic therapeutic intervention. For ex, acute dermatitis often occurs as primary vesicles with associated pruritus (itching). Secondary lesions in the form of crusts occur as the pt scratches, the vesicles are opened, and the exudate dries. Fissure: linear crack or break from the epidermis to dermis Scale: excess, dead epidermal cells produced by abnormal keratinization and shedding Scar: abnormal formation of connective tissue that replaces normal skin Ulcer: loss of the epidermis and dermis Atrophy: depression in skin resulting from thinning of the epidermis or dermis excoriation: area in which epidermis is missing exposing the dermis

CH 26- Resuscitation phase of burn injury -onset of phase? -6 priorities for management during this period?

Immediate care focuses on maintaining an open airway, ensuring adequate breathing and circulation, limiting the extent of injury, and maintaining the function of vital organs. The resuscitation phase is the first phase of the burn injury and it begins at the onset of injury and continues for about 24-48 hrs. During this phase, the injury is evaluated and the immediate problems fluid imbalance (loss), edema, and reduced bf are assessed. The priorities for management during this period are: Secure the airway Support circulation and organ perfusion by fluid replacement Keep the pt comfortable with analgesics Prevent the infection through careful wound care Maintain body temp Provide emotional support

SKIP CH 25- Pediculosis

Pediculosis is a lice infestation: pediculosis capitis (head lice), pediculosis corporis (body lice), and pediculosis pubis (pubic, crab, lice). Human lice are oval and 2-4 mm long. The female louse lays many eggs (nits) at the hair shaft base in hair-bearing areas. The most common manifestation of pediculosis is itching (pruritus). Excoriation from scratching also may be present. Some parasites may also carry disease (ex typhus). Pediculosis capitis occurs more often in people with longer hair. Scalp itching from parasite bites is intense. A secondary infection may also be present from scratching. Bc the louse is difficult to see, examine the scalp for visible white flecks of the nits attached to the hair shaft near the scalp. Matting and crusting of the scalp and a foul odor indicate a probable secondary infection. Pediculosis corporis is caused by lice that live and lay eggs in the seams of clothing. The parasites also cause itching. The only visible sign of infestation may be excoriations on the trunk, abdomen, or extremities. Pediculosis pubis causes intense itching of the vulvar or perirectal region. Pubic lice are more compact and crablike in appearance than body lice and can be contracted from infested bed linens or during sex with an infected individual. Although these lice are usually found in the genital region, they can also infest the axillae, the eyelashes, and the chest. The treatment of pediculosis is chemical killing of the parasites with topical sprays, creams, and shampoos. Agents used include permethrin (Elimite), lindane (Bio-Well, Kwell, Kwellada), or topical malathion (Ovide, Prioderm). Oral agents such as ivermectin (Stromectol) may also be used. In the case of pediculosis capitis, spinosad (Natroba, ParaPro) is a topical agent used as part of an overall lice-management program. Areas where the the pt's head has rested (ex on pillows of chair backs) will also need to be treated. Clothing and bed linens should be washed in hot water with detergent or dry cleaned. The use of a fine-tooth comb helps remove nits but does not cure the infection. For any louse infestation, social contacts are treated when possible.

CH 25P- Impetigo-bacterial infection

Impetigo is contagious and may spread to other parts of patient's body or to other persons. Patient education regarding antibiotics, hygiene, and skin and lesion care. Don't share towels, combs, and so on. Bathe daily with antibacterial soap. Furuncles, boils, or pimples should never be squeezed.

CH 25- Skin Cancer Assessment: Noticing -what is the Koebner's phenomenon?

In addition to skin and race, ask the pt about any family hx of skin cancer and any past surgery for removal of skin growths. Recent changes in the size, color, or sensation of any mole, birthmark, wart, or scar are also significant. Sk in which geographic regions the pt has lived and where currently resides. Obtain info about occupational and recreational activities in relation to sun exposure to chemical carcinogens (ex arsenic, coal, tar, pitch, radioactive waste, radium). Ask whether any skin lesions are repeatedly irritated by the rubbing of clothing. Skin that has been injured previously is at greater risk for cancer development, an effect known as Koebner's phenomenon. Ask the pt if has ever experienced a severe skin injury that resulted in a scar. Examine all scarred skin areas for the presence of potentially cancerous lesions. A bx may be required to r/o cancer in a chronic open wound that fails to close with proper treatment. Skin cancers vary in their appearance and distribution. Although most skin cancers appear in sun-exposed areas of the body, inspect the entire skin surface and an unusual lesions, particularly moles, warts, birthmarks, and scars. Also examine hair-bearing areas of the body, such as the scalp and genitalia. Palpate lesions to determine surface texture. Document the location, size, color, and features of all lesions and any reports of tenderness or itching. Use the ABCDE method of evaluating all lesions for possible melanoma.

CH 25- Pruritus pathophys -what do the physical or chemical agents do to cause itching (2)? -what comorbidity can lead to generalized pruritus? -why is itching more common at night? -what 4 things can make itching worse?

Irritation of the skin is often associated with pruritus (itching), a distressing and often debilitating condition caused by stimulation of itch-specific nerve fibers. Physical or chemical agents either activate nerve fibers directly or stimulate the release of chemical mediators (i.e. histamine), which then act on itch receptors. Itching can be localized or generalized and occur with or without a skin rash. It is estimated that over 50% of elderly pts have xerosis (dry skin), a condition often described generalized discomfort in the absence of skin lesions. Comorbid medical conditions such as DM can also lead to generalized pruritus. Certain localized pruritic skin diseases are more common among the older population, including scabies and bullous pemphigoid. Itching is a subjective condition similar to pain, and severity of the sensation varies among pts. Regardless of cause, pts often report that itching is worse at night when there are fewer distractions. Other conditions that make itching worse include skin dryness, increased temperature, perspiration, and emotional stress.

CH 25P- Stevens-Johnson Syndrome Interventions -name 8 interventions?

Maintaining skin and mucous membrane integrity Attaining fluid balance Preventing hypothermia Relieving pain Prevent infection, consider reverse isolation Reducing anxiety Monitoring and managing potential complications Promoting home and community-based care

CH 25P- Parasitic Disorder Scabies -what meds may be given for scabies (3)? leave it on for how long? why not apply to scalp or face? -repeat treatment how soon? why? -pruritus may continue for several weeks but this does not mean what?

Mite frequently involves fingers and hands; contact may spread infection. Health care personnel should wear gloves when providing care until infection is ruled out. Instruct patient to take a warm, soapy bath; allow skin to cool; and apply prescription scabicide lindane, crotamiton, or 5% permethrin to entire body, not including the face or scalp. Leave on for 12 to 24 hours. Wash clothing and bedding in hot water and dry in a hot dryer. Treat all contacts at the same time. Repeat the treatment in 1 week to prevent reinfestation Pruritus may continue for several weeks and does not mean retreatment is required.

CH 25- Planning/ Responding to Skin Infections For bacterial infections -how often pt is to bathe? squeeze pustules or crusts? -remove what before applying topical drugs? -apply what to furuncles and/or cellulitis for comfort? -most common drug for bacterial skin infections are (2)? -what abx common for MRSA (3)? For fungal infections -what is done to prevent recurrence? -common systemic antifungal abx?

Most skin infections heal well with nonsurgical management. Surgery may be required when an infectious agent is present in deep-tissue layers. Priority nursing interventions focus on pt and family education to prevent infection spread to other body areas or to other people. Meticulous skin care is needed for prevention of infection spread. In some instances drug therapy is needed. Skin care with proper cleansing is the most effective intervention to prevent infection spread. Teach pts with bacterial infections to bathe daily with an antibacterial soap and to not squeeze any pustules or crusts. Teach pts to gently remove crusts before applying topical drugs so the drugs can be more easily absorbed. Teach the pt to apply warm compresses to furuncles or areas of cellulitis to increase comfort. Most superficial skin infections resolve more quickly if the involved skin dries between treatments. Excessive moisture, especially if occluded by dressings, clothing, or bedding, promotes organism growth. Position bedridden pts for optimal air circulation to the area and avoid occlusive dressings or garments. Transmission-based precautions may be needed to reduce infection spread to other people. For most superficial bacterial infections, proper handwashing prevents cross-contamination. However, when hospitalized pts are colonized with abx-resistant Staphylococcus, strict adherence to isolation procedures is necessary. Of the dermatophyte infections, tinea capitis, tinea corporis, and tinea pedis are most easily transmitted to others. Teach pts to avoid sharing personal items, such as hairbrushes, articles of clothing, or footwear. Repeated infections transmitted by dogs or cats indicate that the pet also needs to be treated. Drug therapy for superficial infection involves topical agents. Mild bacterial infections of the skin usually resolve with topical antibacterial treatment. Pts with extensive infections, especially if fever or lymphadenopathy is present, require systemic abx therapy. The most common systemic drugs used for bacterial skin infections are the penicillins and cephalosporins. For those who are allergic to drugs from these classes, tetracyclines, macrolides, or aminoglycoside abx may be used. For pts infected with MRSA, drug therapy may involve IV vancomycin or oral linezolid or clindamycin. Acyclovir (Zovirax, Xerese), valacyclovir (Valtrex), or famiciclovir (Famvir) is used for the treatment of viral infections. Topical treatment decreases the number of active viruses on the skin surface and reduces pain in herpetic infections and localized lesions in immunocompromised pts during an initial outbreak. Topical treatment is of little benefit in recurrent infection. IV administration is limited to severe primary infections, immunosuppressed pts with sx of systemic infection, and recurrent outbreaks. Topical antifungal agents are used for pts with dermatophyte or yeast infections at least twice a day until the lesions have cleared. To prevent recurrence, therapy is usually continued for 1-2 weeks after clearing. In some instances, antifungal powders may also help suppress fungal growth. For widespread or resistant fungal infections, systemic antifungal agents, such as ketoconazole (Nizoral), are given.

CH 25- Health promotion and maintenance of skin infections -for pts with previous chickenpox and thus at risk for shingles, what vaccine can be given? criteria to receive?

Preventing skin infection, especially bacterial and fungal infections, involves avoiding the offending organism and practicing good hygiene to remove the organism before infection can occur. Handwashing and not sharing personal items with others are the best ways to avoid contact with these organisms, including MRSA. For older adults who have had chickenpox and therefore are at risk for shingles (herpes zoster), the vaccine Zostavax is available to prevent VZV reactivation and shingles. The CDC recommends the vaccine for anyone older than 50 y/o who has a health immune system. This one-time subcutaneous injection significantly reduces the incidence of shingles. Cost remains a factor in vaccination, and few insurance carriers currently include this coverage. NURSING SAFETY PRIORITY- Drug Alert: Zostavax is a live viral vaccine and should not be used in pts with severe immunosuppression bc of the risk for viral dissemination. Always check with preceptor before giving any live vaccines to severely immunocompromised pts or those receiving biologic agents for autoimmune disease.

CH 25P- Parasitic Disorder Pediculosis Corporis and Pubis -when to apply vaseline and dosage? -pediculosis corporis is related to what (as a means of increased risk for contraction)?

Pediculosis corporis is a disease related to poor hygiene and of those who live in close quarters. Pediculosis pubis is common and spread chiefly by sexual contact. Bathe in soap and water and apply prescription scabicide or OTC permethrin (NIX). If eyelashes are involved, Vaseline may be applied twice a day for 8 days. Mechanically remove any nits. All family members and sexual contacts must be treated and instructed regarding personal hygiene. All clothing and bedding must be washed in hot water or dry cleaned. Patient and partner should also be scheduled for checkup to assess for coexisting sexually transmitted disease.

CH 26P- Goals of Burns

Prevention Institution of lifesaving measures for the severely burned person Prevention of disability and disfigurement through early specialized and individualized care Rehabilitation through reconstructive surgery and rehabilitation programs

CH 24- Vascular lesions -what can lead to easy or excessive bruising?

Petechiae: small, reddish-purple lesions (< 0.5 mm in diameter) that do not fade or blanch when pressure is applied. They often indicate increased capillary fragility. Petechiae of the lower extremities often occur with stasis dermatitis, a condition usually seen in chronic venous insufficiency. Petechiae found below the nipple may be indicative of serious underlying medication problem such as disseminated intravascular coagulation (DIC). Spider Angioma Cherry Angioma Ecchymosis (bruises): larger areas of hemorrhage. In older adults, bruising is common after minor trauma to skin. Certain drugs (ex ASA, warfarin, corticosteroids) and low platelet counts lead to easy or excessive bruising. Anticoagulants and decreased number of platelets disrupt clotting action, resulting in ecchymosis.

CH 25- Chart 25-1: Preventing Pressure Injuries (p. 449) Positioning -what materials can pad contact surfaces bc of its pressure-redistribution properties? -elevate HOB and side-tilt at what angle? -what can you place between two bony surfaces? Nutrition -ensure how much fluid intake per day? Skin care -what can you do to room's temperature? -do not do what in terms of skin care? Skin Cleaning -use what to clean incontinence? -use what temp water in cleaning? -do not use what on perineum?

Positioning -foam, silicone gel, air pad materials can pad contact surfaces bc of its pressure-redistribution properties? -elevate HOB and side-tilt at no greater than 30 degrees -place pillow or foam wedges between two bony surfaces Nutrition -ensure 2,000-3,000 mL fluid intake per day Skin care -humidify room -DO NOT MASSAGE BONY PROMINENCES Skin Cleaning -use mild, heavily fatted soap or gently commercial cleanser to clean incontinence -use what tepid rather than hot water in cleaning -do not use powders or talc directly on perineum

SKIP CH 25- Pressure Injury Incidence/Prevalence

Pressure injury development is a problem found among pts in any care setting, including the home. Although new products are available for prevention and treatment, many hospitalized pts still experience pressure injury formation, which contributes to morbidity and mortality in this pt population.

CH 25- Pressure Injury health promotion and maintenance

Pressure mapping with a computerized tool that measures pressure distribution during sitting or lying can identify specific body areas at risk for breakdown and can help plan interventions for pts who are bedridden or wheelchair bound. The map is displayed in colors on the computer screen based n temp differences. Red indicates areas of greater heat production and increased pressure loads. Blue indicates cooler areas under lower pressure. When used in combination with risk assessment tools, pressure mapping helps identify problem areas before skin changes can be seen and allows for more targeted prevention strategies.

CH 25- Pressure Injury Mechanical Forces

Pressure occurs as a result of gravity. Dependent tissues in contact with a fixed surface experience varying degrees of pressure. Pressure is determined by the amt and distribution of weight exerted at the point of contact and the density of the contacting surface. Excessive or prolonged pressure compresses bv at the point of contact, such as over bony prominences. Pressure occurs when the pt is positioned on a hard surface that does not redistribute the weight, such as when lying on a hard floor for hours after a fall or when remaining in the same position too long. Unrelieved pressure leads to ischemia, inflammation, and tissue necrosis. Friction occurs when surfaces rub the skin and irritate or tear fragile epithelial tissue. Such forces are generated when the pt is dragged or pulled across the bed linen. Shearing forces are generated when the skin itself is stationary and the tissues below the skin (ex fat, muscle) shift or move. The movement of the deeper tissue layers reduces the blood supply to the skin, leading to skin hypoxia, anoxia, ischemia, inflammation, and necrosis. A shear ulcer usually occurs when a pt is in a wheelchair or in bed in a semi-sitting position and gradually slides downward. The skin over the sacrum may not slide down at the same pace as the deeper tissues, mechanically "shearing" the skin, causing bv to stretch and break. Shearing leads to soft-tissue ischemia and deep-tissue ulcer, even though no external break in skin integrity is observed.

CH 26P- Emergent Phase of Burn Injury-on the scene --> ED -Treat patient with falls and electrical injuries as potential for what kind of injury? -Patient with burns exceeding __% to __% should have what intervention done? -Pt with electrical burns should obtain? -Medication should only be given via what route?

Prevent injury to rescuer Stop injury: extinguish flames, cool the burn, irrigate chemical burns ABCs: Establish airway, breathing, and circulation Start oxygen and large-bore IVs Remove restrictive objects and cover the wound Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history Note: Treat patient with falls and electrical injuries as for potential cervical spine injury. Surgical Management of Burns in Emergent Phase Escharotomy Patient is transported to emergency department Fluid resuscitation is begun Foley catheter is inserted Patient with burns exceeding 20% to 25% should have an Ng tube inserted and placed to suction Patient is stabilized and condition is continually monitored Patients with electrical burns should have ECG Address pain; only IV medication should be administered Psychosocial consideration and emotional support should be given to patient and family

CH 24- Primary skin lesions

Primary lesions develop as a direct result of a disease process. Macule: circumscribed, flat are with a change in skin color (<1cm) Papule: elevated, solid lesion (<1cm) Vesicle: circumscribed, superficial collection of serous fluid (<1cm) Plaque: circumscribed, elevated superficial, solid lesion (>1cm) Wheal: firm, edematous, irregularly shaped areas Pustule: elevated, superficial lesion filled with purulent fluid

CH 25- Pruritus is caused by?

Pruritus r/t a physical xerosis (dry skin)or chemical agent with stimulation of "itch" specific nerve at the dermal-epidermal junction.

CH 25- Psoriasis Pathophys -explain pathophys involved? -pts with psoriasis often improve with? -what hormonal changes can aggravate psoriasis? -what drugs can aggravate psoriasis (3)? -T/F obesity can aggravate psoriasis? -what other disease often develops from psoriasis?

Psoriasis is a chronic autoimmune disorder affecting the skin with exacerbations and remissions. It results from overstimulation of the immune system (Langerhans' cells) in the skin that activates T-lymphocytes. These cells then target the keratinocytes, causing increased cell division (bc some degree of cellular regulation is lost) and plaque formation. Even though psoriasis cannot be cured, pts can often achieve control of sx with proper management. Psoriasis lesions are scaled with underlying dermal inflammation from an abnormality in the growth of epidermal cells. Normally basal cells take about 28 days to reach the outermost layer where they shed. In a person with psoriasis, the rate of cell division is speeded up so cells are shed every 4-5 days. Genetic Considerations: A genetic predisposition is associated with psoriasis as indicated by the fact that, when one identical (monozygotic) twin develops the disease, the second twin also develops it about 70% of the time. Variation in many gene sequences, labeled PSORS1 through PSORS13, influences the development of this autoimmune disorder. It is likely that different variations of these gene loci also influence individual pt responses to therapy. Always ask about a family hx of the disorder when assessing the pt with psoriasis. Many environmental factors lead to outbreaks and influence the severity of sx, but these vary from person to person. Triggering factors may be local or systemic. A psoriatic lesion may appear after skin trauma (i.e. Koebner's phenomenon, in which a previously injured area is more susceptible to development of cancer or chronic skin problems) such as surgery, sunburn or excoriation. Pts with psoriasis often improve with more exposure to sunlight. Systemic factors that can aggravate the disease include infection (severe streptococcal throat infection, Candida infection, upper respiratory infections), hormonal changes (e.g. puberty, menopause), stress, drugs (lithium, beta-blocking agents, indomethacin), obesity, and the presence of other diseases. Some pts with psoriasis also develop debilitating psoriatic arthritis. This arthritis may lead to severe joint changes similar to those seen in RA and indicates that psoriasis is a systemic disorder.

REVIEW CH 25P- Melanoma -peak incidence age range? -types (3)?

Risk factors Worldwide incidence and mortality rates are increasing Peak incidence, 20 to 45 years of age Types: superficial spreading, lentigo-maligna melanoma, nodular melanomas Treatment: surgical excision, other therapies Metastasize

SKIP CH 25- Scabies

Scabies is a contagious skin infection caused by mite infestations. It is transmitted by close contact with an infested person or infested bedding. Infestation is common among pts with poor hygiene or crowded living conditions. The scabies mite is carried by pets and is found among homeless individuals and institutionalized older pts. Health care personnel are at risk for contracting scabies from contact with an infected pt or his or her bed linen. Curved or linear ridges in the skin are a feature of scabies. The itching is very intense, and pts often report that it becomes unbearable at night. The visible, horizontal white skin ridges are formed by burrowing of the mite into the outer skin layers. Examine the skin between the fingers and on the palms and inner aspects of the wrists, where these ridges are most common. A hypersensitivity reaction to the mite results in excoriated erythematous papules; pustules; and crusted lesions on the elbows, nipples, lower abdomen, buttocks, and thighs and in axillary folds. Males can have lesions on the penis. Infestation is confirmed by taking a scraping of a lesion and examining it under the microscope for mites and eggs. Close contacts also should be examined for possible infestation. Treatment involves the use of scabicides, such as permethrin (Acticin), lindane (Kwell, Kildane, Scabene, Thionex), crotamitron (Eurax) or benzyl benzoate (Ascabiol). Laundering clothes and personal items with hot water and detergent is sufficient to eliminate the mites.

CH 24P- Gerontological considerations -skin (4)? -hair (3)? -nails (3)?

Skin Less subcutaneous tissue Decrease extracellular water Decrease activity of sweat glands Less blood supply to tissue Hair Decrease oil Accumulation of androgen and less estrogen Decreased melanin and melanocytes (gray hair) Nails Decreased blood supply to periphery Increased keratin (ridging Decreased circulation

CH 25P- The Care of the Patient With Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome—Assessment

Skin inspection Oral cavity inspection Vital signs Respiratory secretions Fatigue Pain level Coping mechanism

CH 26- Depth of burn injury Superficial-thickness wound -what layer(s) is/are damaged? healing time? 2 ex?

Superficial-thickness wounds have the least damage bc the epidermis is the only part of the skin that is injured. The epithelial cells and basement membrane, needed for total regrowth, remain present. These wounds are caused by prolonged exposure to low intensity heat (ex sunburn) or short (flash) exposure to high-intensity heat. Redness with mild edema, alterations in comfort, and increased sensitivity to heat occurs as a result. Desquamation (peeling of dead skin) occurs 2-3 days after the burn. The area heals rapidly in 3-6 days without a scar or other complication.

CH 25- Surgical management of skin cancer explain the following surgical intervention options for skin cancer: -cryosurgery -curettage and electrodessication -excisional bx -moh's surgery

Surgical intervention is needed to manage any type of skin cancer. It can range from local removal of small lesions to massive excision of large areas of the skin and underlying tissue for treatment of melanoma. Surgical types of skin cancer include: Cryosurgery- cell destruction by the local application of liquid nitrogen (-200C) to isolated lesions, causing cell death and tissue destruction. Curettage and electrodesiccation- removal of cancerous cells with the use of a dermal curette to scrape away cancerous tissue, followed by the application of an electric probe to destroy remaining tumor tissue. Excisional bx- total surgical removal of small lesions for pathologic examination. Mohs' surgery- a specialized form of excision usually for basal and squamous cell carcinomas. Tissue is sectioned horizontally in layers, and each layer is examined histologically to determine the presence of residual tumor cells. Wide excision- deep skin resection often involving removal of full thickness skin in the area of the lesion. Depending on the tumor depth, subcutaneous tissues and lymph nodes may also be removed.

CH 25- Psoriasis Physical Assessment/ Signs and Sx -which is the most common type of psoriasis? -what kind of distribution is common?

The appearance of psoriasis and its course vary among pts. Typically during flare-ups of the disease, lesions thicken and extend into new body areas. A psoriasis responds to treatment, lesions, become thinner with less scaling. Psoriasis vulgaris is the most common type of psoriasis, with thick, reddened papules or plaques covered by silvery white scales. Borders between the lesions and normal skin are sharply defined. Patches are less red and moister in skinfold areas. Lesions are usually present in the same areas on both sides of the body (bilateral distribution). Common sites include the scalp, elbows, trunk, knees, sacrum, and outside surfaces of the limbs. Facial skin is rarely affected. Te pt may have only a few lesions, or the entire skin surface may be affected. Exfoliative psoriasis (erythrodermic psoriasis) is an explosively eruptive and inflammatory form of generalized erythema and scaling but no obvious lesions. Fluid loss with this severe inflammatory reaction can lead to dehydration and hypothermia or hyperthermia. Palmoplantar pustulosis (PPP) is a type of psoriasis that forms pustules on the palms of the hands and soles of the feet along with reddened hyperkeratotic plaques. The course of the disease is cyclic, with new outbreaks of pustules occurring after older lesions have resolved. PPP is difficult to treat, and pts often have social and physical problems.

SKIP CH 26- Depth of burn injury

The severity of a burn is determined by how much of the body surface area is involved and the depth of the burn. The degree of tissue integrity loss is related to the agent causing the burn, the temperature of the heat source, and how long the skin is exposed to it. Differences in skin thickness in various parts of the body also affect burn depth. In areas where the skin is thin (ex eyelids, ears, nose, genitalia, totps of the hands and feet, fingers, and toes), a short exposure to high temperatures causes a deep burn injury. The skin is thinner in older adults, which increases their risk for greater burn severity, even at lower temperatures of shorter duration. Burn wounds are classified as superficial thickness wounds, partial thickness wounds, full thickness wounds, and deep full thickness wounds. The partial thickness wounds are further divided into superficial and deep subgroups. Burns are classified as minor, moderate, or major, depending on the depth, extent, and location of injury.

REVIEW CH 25- Pressure-redistribution technique Support surfaces and devices

The cornerstone in the prevention and management of pressure injuries is maintaining adequate pressure redistribution so pressure over bony prominences remains below the capillary closing pressure. Capillary closing pressure is the pressure needed to occlude skin capillary blood flow and normally ranges from 12-32 mm Hg. An effective pressure-redistribution surface or device keeps tissue interface pressure below the capillary losing pressure, thus promoting adequate tissue perfusion and gas exchange. Most support surfaces and devices have a standardized guaranteed pressure-redistribution reading; however, these readings do not ensure that capillary blood flow for any given pt is adequate. Observe skin color, capillary refill, tissue integrity, and temperature directly to determine capillary flow adequacy. Products that redistribute tissue load are available in several forms: a specialty bed replacements, mattress replacements, mattress overlays, seat cushion replacements, seat cushion overlays, and heel-suspension devices. Choosing the correct product is impt to the success f an prevention or treatment plan. Factors to consider when selecting a product include: Number and severity of existing pressure injuries Risk for developing new pressure injuries Pt's ability to reposition self to relieve pressure-related discomfort Need for microclimate control to help manage skin temperature and moisture Need to reduce shearing forces Compatibility of product with care setting Support surfaces are classified as either nonpowered (static) or powered (dynamic). Static devices use gel, water foam, or air to increase the body surface area that comes in contact with the surface and reduce interface pressure. A static high-specification reactive foam mattress with frequent repositioning is recommended for pts at high risk for pressure injury development and for management of those with existing stage 1 or stage 2 pressure injuries. Dynamic systems are comprised of cells that inflate and deflate to continuously alter the area of the body that is bearing the load. Alternating pressure surfaces with small air cells are considered to be less effective than those with air compartments > 10 cm. Consider the use of a dynamic support surface for immobile pts when manual repositioning is medically contraindicated; when the number and severity of existing pressure injuries limit turning options; for management of stage 3, stage 4, unstageable pressure injuries; and for suspected deep-tissue injury when repositioning is ineffective. Evaluate the surface daily for effectiveness in redistributing pressure, reducing discomfort, managing the microclimate and shear, and eliminating "bottoming out." Bottoming out occurs when the product is not providing adequate pressure redistribution for the pt's size and weight and the pt's bony prominences sink into the mattress or cushion. If the pt has a pressure injury involving the heel, use a heel-suspension device to elevate the heel and offload pressure completely without placing pressure on the achilles tendon. Check heel suspension devices periodically to assess skin integrity. Pressure-redistribution devices lower pressure below that of a standard hospital mattress or chair surface but do not reduce pressure consistently below the capillary closing pressure these devices are effective for preventing pressure injuries only when used together with a turning schedule and there preventive skin-care measures.

CH 26- GI changes associated with burns -can lead to what GI condition? -how does abdominal distention occur? -Curling's ulcer? what drugs to give to treat (2)?

The fluid shifts and decreased CO that occur after injury decrease blood flow to the GI tract. Gastric mucosal tissue integrity and motility are impaired. The sympathetic nervous system stress response increases secretion of epinephrine and norepinephrine, which inhibit GI motility and further reduce blood flow to the area. Peristalsis decreases, and a paralytic ileus may develop. Secretions and gases collect in the GI tract, causing abdominal distention. Curling's ulcer (acute gastroduodenal ulcer that occurs with the dress of severe injury) may develop within 24 hrs after a severe burn injury bc of reduced GI blood flow and mucosal damage. The mucus lining the stomach normally protects the tissue from the hydrogen ions secreted into the stomach with decreased gastric mucus production and increased hydrogen ion production, ulcers may develop. This complication is now less common bc of the use of H2 histamine blockers, PPIs, drugs that protect GI tissues, and early enteral feeding.

CH 25- Skin cancer incidence/prevalence -skin cancer highest among what skin color and what age? -what elemental exposure increases risk? -melanoma is what percent of total skin cancer cases but has highest what?

The incidence of skin cancer is highest among light-skinned races and adults older than age 55. Skin cancer occurs more often among those who work outdoors, live at higher altitudes or lower latitudes, or spend much time sunbathing. Occupational exposure to arsenic or other chemicals carcinogens also increases risk. Melanoma reflects only 1% of total skin care cases but has one of the highest associated mortality rates. Genetic Considerations: Genetic mutations in the CDKN2A and CDK4 have been identified for some cases of familial melanoma. These mutations in a suppressor gene result in loss of cellular regulation for cell growth. Other genetic considerations for melanoma are that some specific mutations in the genes of the actual tumor cells increase the response of these cells to the targeted therapy. All melanomas should be tested for mutations of the BRAF and KIT genes. Always ask pts who have diagnosed melanoma whether any other family members have ever had this disease.

CH 25- Skin cancer health promotion and maintenance -what does secondary prevention mean?

The most effective prevention strategy for skin cancer is avoiding or reducing skin exposure to sunlight. However, even when adults understand the cause of skin cancer and the seriousness of the disease, preventive behaviors are not always practiced. Teach all individuals to avoid tanning beds and salons. Secondary prevention (early detection) is critical to survival with melanoma. Teach adults to be aware of their skin markings. Keeping a total body spot and lesion map can provide baseline information about suspicious new lesions and help identify changes in existing lesions. Once a map is made, the person should systematically inspect his or her body monthly for new lesions and for changes in any existing lesions by performing thorough skin self-examination (SSE). Some people find taking pictures of their skin on a regular basis makes identifying changes easier. Teach everyone to evaluate all skin lesions using the ABCDE guide for melanoma and to consult with PCP to examine any lesion having unusual features. When lesions such as moles are present, they should be monitored annually by a dermatologist or other health care professional.

CH 26- Skin functional changes with burns -why is pain and sensitivity felt in partial thickness burns but not in full thickness burns?

The skin has many functions when tissue integrity is intact. It is a protective barrier against injury and microbial invasion. Burns break this barrier, greatly increasing risk for infection. The skin helps maintain delicate fluid and electrolyte balance essential for life. After a burn injury, massive fluid loss occurs through excessive evaporation. The rate of evaporation is in proportion to the total body surface area (TBSA) burned and the depth of injury. The skin is an excretory organ through sweating. Full-thickness burns destroy the sweat glands, reducing excretory ability. The sensations of pain, pressure, temperature, and touch are triggered on the skin in normal daily activities which allows a person to react to changes in the environment. All burn injuries are painful. With partial thickness burns, nerve endings are exposed, increasing sensitivity and pain. With full-thickness burns nerve endings are completely destroyed. At first, these wounds may not transmit sensation except at wound edges. Despite this destruction, pts often have dull or pressure-type pain in these areas. Skin exposed to sunlight activates vitamin D. Partial thickness burns reduce activation of vitamin D, and this function is completely lost in areas of full thickness burns. The internal body temp remains within a narrow range (8.2-109.4F) compared to the temperatures of the external environment. Skin tissue integrity is impt in maintaining normal body temperature. Circulating blood in the skin provides and dissipates heat efficiently. When the heat is applied to the skin, the temperature under the dermis rises rapidly. As soon as the heat source is removed compensatory processes quickly return the area to a normal temperature. If the heat source is not removed or if it is applied at a rate that exceeds the skin's capacity to dissipate it, cells are destroyed. Physical identity is partly determined by the skin's cosmetic quality, which contributes to each individual's unique appearance. A pt who sustains a major burn often develops reduced self-image and other psychosocial problems as a result of appearance changes.

CH 26- Skin anatomic changes with burns

The skin is the largest organ of the body. Each of its two major layers, the epidermis and dermis, has several sublayers. The epidermis is the outer layer of skin. It can grow back after a burn injury bc the epidermal cells surrounding sweat and oil glands and hair follicles extend into dermal tissue and regrow to heal partial thickness wounds. Together the sweat and oil glands and the hair follicles are the dermal appendages, which vary in depth in different body areas. For ex, the sweat and oil glands in the palm of the hand and the sole of the foot extend deep into the dermis. This allows for healing of deep burns in these areas. The epidermis has no bv, and nutrients must diffuse from the second layer of skin, the dermis. The dermis is thicker than the epidermis, and is made up of collagen, fibrous connective tissue, and elastic fibers. Within the dermis are the bv, sensory nerves, hair follicles, lymph vessels, sebaceous glands, and sweat glands. When burn injury occurs, skin may regrow as long as parts of the dermis are present. When the entire dermal layer is burned, all cells and dermal appendages are destroyed, and the skin can no longer restore itself. The subcutaneous tissue lies below the dermis and is separated from the dermis by the basement membrane, a thin, noncellular protein surface. With deep burns, the subcutaneous tissues may be damaged, leaving boness, tendons, and muscles exposed.

CH 25- Psoriasis Planning/Responding what is used to treat moderate to severe psoriasis (3)? -how do corticosteroids treat psoriasis?

There is no cure for psoriasis yet. Priority nursing strategies include teaching the pt about the disease and its treatment and providing emotional support for the changes in body image often experienced with psoriasis. Topical Therapy The topical agents used to treat moderate-to-severe psoriasis are topical steroids, topical tar and anthralin preparations, and UV light. Corticosteroids have anti-inflammatory actions. When applied to psoriatic lesions, they suppress cell division. The effectiveness of a topical steroid depends on its potency and ability to be absorbed into the skin. The more potent agents are used as therapy for pts with psoriasis. Ex of commonly prescribed topical corticosteroids include clobetasol (Temovate, Dermovate), triamcinolone (Aristocort, Triaderm), fluocinolone (Synalar, Fluoderm), and betamethasone (Diprolene). Teach pts to enhance the skin penetration of these drugs by applying the steroid directly to the skin. When prescribed, suing warm, moist dressings and an occlusive outer wrap or plastic (film, gloves, booties, or similar garments) may enhance absorptions. Avoid using high potency steroids on the face, scalp, or skinfold areas bc of the potential for increased absorption and side effects. Tar preparations applied to the skin suppress cell division form impaired cellular regulation and reduce inflammation. These drugs are are available as ointments, lotions, gels, and shampoos. The ointments are messy, cause straining and have an unpleasant odor. Topical therapy with anthralin (Zithranol, Anthraforte, Drithocreme, Psoriatec) a hydrocarbon similar in action to tar, also relieves chronic psoriasis. These drugs can be used alone or in combination with coal tar baths and UV light. Teach the pt to apply the high-potency anthralin, suspended in a stiff paste, to each lesion for short periods of time as directed by MD. The drug is a strong irritant and can cause chemical burns if left on lesions too long or not washed off completely after each treatment. Remind the pt to check for local tissue reaction and to take care to prevent this drug from coming into contact with uninvolved skin. Other topical therapies can be effective for many pts with mild-to-moderate psoriasis. These drugs include calcipotriene (Dovonex), a synthetic form of vitamin D that regulates skin cell division, and tazarotene (Avage, Tazorac), a derivative of vitamin D that slows cell division and reduces inflammatory response. In some cases, calcitriol (Vectical ointment) has been helpful but is very expensive. NURSING SAFETY PRIORITY- Drug Alert: Tazaroc is teratogenic (can cause birth defects) even when used topically. Teach sexually active women of childbearing age using this drug to adhere to strict contraceptive measures. Light Therapy UV radiation is a physical agent commonly used as a topical therapy in many skin conditions, including psoriasis. UV B (UVB) light, which produces more energy is responsible for the obvious biologic effects of the sun such as burning. Although the sun is an inexpensive source of UV radiation, better availability and intensity control occur with the use of artificial light sources. These sources include lamps or cabinets containing UV tubes. The use of commercial tanning beds is not recommended for the pt with psoriasis. UV therapy is limited by exposure time and effects on the surrounding normal skin. The time of exposure is gradually increased to achieve a mild suntan effect without burning or tenderness. The pt's skin pigmentation determines the exposure times. Bc of the extremely high intensity of most artificial UVB light sources, therapy is measured in seconds of exposure, and pts must wear eye protection during treatment. Narrow-band UVB light therapy, although intense, can shorten the time to effectiveness and reduce the number of exposures needed to maintain the response. Light therapy with lasers can be effective in controlling mild-to-moderate psoriasis. Laser sources, whether administered in a continuous or pulsed exposure, allow for better focus on the lesions and reduce exposure to the surrounding normal skin. Teach pts to inspect the skin carefully each day for signs of overexposure. If tenderness on palpation occurs and severe erythema or blister formation develops, notify the PCP before therapy is resumed. Psoralen and UV A (PUVA) therapy involves the ingestion of a photosensitizing agent (psoralen) 45-60 min before exposure to UVA light. Therapy sessions are limited to 2-3 x a week and are not given on consecutive days. Exposure is gradually increased until tanning occurs. Dosages are adjusted according to the erythema reaction of normal skin and the response of psoriatic lesions. Teach the pt to check for redness with edema and tenderness. If these are present, treatment must be interrupted until they subside. Bc psoralen is a strong photosensitizer, pts must wear dark glasses during treatment and for the rest of the day. Systemic Therapy Oral systemic agents are often prescribed when psoriasis fails to respond to topical treatment. Agents commonly used include acitretin (Soriatane), a vitamin A derivative and apremilast (Otezla), a small molecule inhibitor that inhibits the spontaneous production of tumor necrosis factor alpha (TNF-alpha). NURSING SAFETY PRIORITY- Drug Alert: Both acitretin and bexarotene are teratogenic. Teach sexually active women of childbearing age using this drug to adhere to strict contraceptive measures. A variety of biologic (immunomodulating) agents that alter the immune response and prevent overstimulation of keratinocytes from impaired cellular regulation are now being used to manage moderate-to-severe plaque psoriasis. These agents may be prescribed when other drugs are not effective and when psoriatic arthritis is also present. Most of these drugs are given by IV infusion, IM injection, or subcutaneous infection. All of these agents induce some degree of immunosuppression, and pts are at an increased risk for serious infection. NURSING SAFETY PRIORITY- Drug Alert: Instruct pts to discontinue the biologic agent and notify PCP asap if signs and sx of an active infection occur. Biologics currently approved for the treatment of psoriasis are listed in Chart 25-8 and these drugs should not be used by pts who are pregnant or breastfeeding. Other less commonly used systemic drugs for the pt whose disease is resistant to topical therapy include methotrexate (Folex, Mexate), cyclosporine (Sandimmune), and azathioprine (Imuran). The many health risks associated with these therapies must be considered along with the potential benefits, especially in older adults.

CH 25- Stevens-Johnson Syndrome -what is Steven-johnson sydrome? what are the 8 specific things that cause it? -discontinuation of the above mentioned thing will lead to gradual healing in how long? what will also happen to skin?

Toxic epidermal necrolysis (TEN) and Steven-Johnson Syndrome (SIS) are life-threatening cutaneous reactions to medications. Thought to be variations in severity of the same immune process, TEN/SIN is characterized by diffuse erythema and blister formation, often involving the MM. The most common causative drugs are allopurinol, antiepileptics, NSAIDs, chemotherapy agents, sulfonamides, pyrazolones, barbiturates, and abx. Discontinuation of the drug is usually followed by gradual healing in 2-3 weeks, with widespread peeling of the epidermis. This problem can occur at any age and as a result of almost any drug therapy. However, older pts with cancer who are receiving chemotherapy, some targeted therapies, and immunotherapy are at greatest risk. Other precipitating factors include stem cell transplantation and neutropenia-induced infections. The drug though to be causing a toxic reaction is discontinued, and management focuses on systemic support and prevention of secondary infection. Pts are often admitted to burn units, where fluid and electrolyte balance, caloric intake, and hypothermia can be closely monitored. Topical antibacterial drugs are used to suppress bacterial growth until healing occurs.

CH 25- Urticaria (hives) is r/t?

Urticaria (Hives) r/t exposure to allergens that release histamine into dermal tissue. White or red edematous papules created in response to blood vessel dilation and plasma protein leakage. Can be r/t foods, insect Bites, drugs

CH 25- Urticaria (hives) -what are some common causes of urticaria (7)? -what antihistamine usually given to treat? -what is pt to avoid bc it can further dilate bv and make urticaria worse? explain one of which has relation to antihistamines?

Urticaria (hives) is a rash of white or red edematous papules or plaques of various sizes. This problem is usually caused by exposure to allergens, which releases histamines into the skin Bv dilation and plasma protein leakage lead to formation of lesions or wheals. Some common causes of urticaria include drugs, temperature extremes, foods, infection, diseases, cancer, and insect bites. Management focuses on removal of the triggering substance and relief of sx. Bc of skin reaction is caused by histamine release, antihistamines such as diphenhydramine (Benadryl) are helpful. Teach the pt to avoid overexertion, ETOH intake, and warm environments, which further dilate bv and make urticaria worse. ETOH increases sedating effect of antihistamines, increasing the risk for falls

SKIP CH 25- Lab Assessment for Skin Infection

When pustules are present in bacterial infections, the infecting organism is confirmed by swab culture of the purulent material. Blood cultures may be helpful if fewer and malaise are present. Various cultures and other techniques are used to identify viral and fungal infections.

CH 24- Chart 24-3 Assessing Changes in Dark Skin -three ways to assess cyanosis? -two areas to check for jaundice? -if pt has thrombocytopenia, what may be seen and where?

cyanosis -examine lips and tongue for gray color -examine nail beds, palms, soles for blue tinge -examine conjunctiva for pallor jaundice -check for yellow tinge to oral MM, especially hard palate -examine sclera nearest iris rather than corners of eye bleeding -if pt has thrombocytopenia, petechiae may be present on oral mucosa or conjunctiva

CH 25P- Pressure injuries are loss of tissue integrity r/t (4)?

compression of bony prominence limited mobility Ischemia friction or shearing

CH 26- Fig 26-7 Physiologic actions of the sympathetic nervous system compensatory responses to burn injury (early phase) (p.487)

increased catecholamine release respirations rapid increased aldosterone release n/v skin vasoconstricted capillary refill slow increased blood sugar increased release of glycogen stores

CH 25- Two pressure-redistribution techniques?

support surfaces and devices positioning

CH 24- Review diagnostic procedures skin bx immunofluorescence patch testing skin scrapings tznack smear -purpose? -where obtained? -significant result? wood's light examination -what does it entail? -used for (2)?

tznack smear -used to confirm but not ID viral infection -smear obtained from base of lesion -presence of multinucleated cells indicates infection wood's light exam -UV black light used over areas of skin infection (blue-green or red indicates infection) -hypopigmented skin can also be see under black light in light skin pts, making evaluations easier.