Integumentary & HEENT

basal cell carcinoma (BCC)

Basal cell carcinomas are translucent, raised, and smooth. They are usually on sun-exposed skin and rarely metastasize or cause death. They are the most common type of skin cancer.

Burns

Burns were formerly classified by degrees (first through fourth), but are now classified by the depth of the injury. Superficial burns involve only the epidermal layer of skin and do not blister but are painful, dry, red, and blanch with pressure. The pain subsides after 2-4 days and resolves within 6 days (example: sunburn, minor scalding from hot food). Partial thickness burns include two subcategories: Those involving the epidermis (superficial) and those involving portions of the dermis (deep). Superficial partial thickness burns form blisters within 24 hours and are very painful, red, and weeping but can still blanch with pressure. They heal in 1-3 weeks. Deep partial thickness burns extend into the deeper dermis and can be very painful or painful only to pressure. They appear red and waxy white or patchy red and white with wet blisters and blanch slowly, if at all. They heal in 3-9 weeks with scarring and functional limitation if located over a joint. Full thickness burns: These burns destroy all layers of the dermis and may involve subcutaneous tissue. These burns do not hurt. The skin appears white or gray or even blackened. No blisters will develop. Pale full thickness burns may appear like normal skin, but there is no blanching and the skin is no longer elastic due to the damage. Deep full thickness burns appear black and dry and are painless. They are potentially life-threatening, extending through the skin into fascia, muscle, or bone. During the resuscitation phase of burn injury, and before fluid replacement begins, expected changes in serum include: increased hemoglobin, hematocrit, BUN, and chloride due to fluid volume losses; elevated glucose due to stress response and altered uptake across tissues; decreased sodium, as sodium is trapped in edema fluid; increased potassium due to tissue damage, and decreased albumin due to increased permeability of vascular membranes. In arterial blood gas analysis, PaO2 is slightly decreased and PaCO2 is elevated if respiratory injury is present, and pH is decreased due to metabolic acidosis. The emergency department nurse reviews laboratory values on a client with deep partial-thickness burns to the face and trunk. Which values can the nurse expect during the emergent phase? Expect: Hematocrit 55% Hematocrit level will be increased as a result of fluid volume loss. (Hematocrit normal values are 37-52%) Potassium 6.1 mEq/L Potassium level will be increased due to tissue destruction and red blood cell hemolysis. (Potassium normal is 3.5-5.6 mEQ/L) Arterial pH 7.31 Arterial pH will be low due to metabolic acidosis. (Arterial pH normal is 7.35-7.45) Wrong: Hemoglobin 9.6 g/dL Hemoglobin level will be increased as a result of fluid volume loss. (Hemoglobin normal values are 12-18 g/dl) Blood urea nitrogen (BUN) 8 mg/dL BUN levels will be increased as a result of fluid volume loss. (BUN normal is 10-20 mg/dl) Clients who have burns that are greater than 20% TBSA need to undergo aggressive fluid resuscitation for the first 24 hours after injury. There are several formulas that can be used to calculate fluid requirements. The most common formula estimates a need for a crystalloid solution of 2-4 mL/kg body weight / %TBSA in these first 24 hours. Lactated Ringer solution is the most commonly used fluid, as it is close in composition to normal body fluid. It is important that the nurse frequently monitor the client's vital signs and urine output during the fluid resuscitation intervention phase. Burns occur as a result of chemicals, electric current, radiation, or heat that comes in contact with the body. The state of burns is impacted by the duration of contact, type of tissue contacted, and type of agent. The highest mortality of burns occur among the population under 4 years of age and adults over 65 years. Chemical Chemical burns occur when tissue comes in contact with organic compound, acids, or alkalis. Thermal Thermal burns are caused by flames, hot liquids, semi liquids (steam), or hot objects. Singed body hair is most likely from thermal burns. Electrical Electrical burns result when electrical current generates heat that comes into contact with tissue. Radiation Radiation burns result when tissue comes in contact with a radiation source.

What LVN/LPN can do

The client with a pressure ulcer needs frequent skincare and evaluation. The RN delegates care as appropriate to unlicensed assistive personnel (UAPs) and LPN/LVNs. As part of delegation, the RN ensures that team members to whom care is delegated know how to perform the care and know to communicate any changes in client status immediately to the RN or health care provider. The RN should not delegate the care of an unstable client nor clients being admitted to or discharged from the unit, as that care requires the skill of the RN. When the RN delegates aspects of a client's care, the RN is responsible for ensuring that each task is assigned appropriately and completed according to the standard of care. According to the NCLEX-PN test plan, PNs perform the following: Urinary catheterization Administration of drugs by the PO, IM, and subcutaneous or intradermal route Giving oxygen or other medications by inhalation, ear, eye, nose, or skin Administration of drugs by gastrointestinal or nasogastric tube Monitoring IV flow rate and administering IV piggyback (secondary) medications With required training, the PN can administer IV medications after the first dose has been administered by a registered nurse.

Full thickness burns

The client with full thickness burns is at high risk for fluid imbalance due to third spacing or capillary leak syndrome. This results from leak of plasma from the vascular space into the interstitial space. The nurse should gather all relevant data related to this complication to provide to the health care provider to ensure the best prescription to treat the hypotension. Other relevant data would include current sodium, potassium, albumin, and hematocrit levels. Which to do first? --> apparently assess UO to gather evidence of fluid volume deficit. Increase the client's IV fluid volume rate. Fluid resuscitation should be attempted to bring up blood pressure but the nurse should first fully assess the client and communicate findings to the provider in order to determine fluid resuscitation measures. Place the client in the reverse Trendelenburg position. Positioning can be an important initial intervention for the client who has hypovolemia and hypotension. The nurse should assess for dizziness and take action based on findings. The goal is to lower the head of bed to improve cerebral perfusion, and reverse Trendelenburg places the head higher than the heart, so it is not recommended. Trendelenburg (or modified) or the supine position may be used. Assess the client's current urine output volume. The client's assessment indicates potential intravascular fluid volume deficit. The nurse should gather further evidence including accurate urine output and current weight to report to the health care provider. Request a prescription for vasopressors. The client's results do not indicate a need for vasopressors. Fluid resuscitation should be attempted to bring up blood pressure before considering the use of vasopressors. Full thickness burns destroy the entire epidermis and dermis, leaving no skin cells to regrow. These wounds will require grafting to heal. The full thickness burn is covered in a dry, hard, leathery eschar, which will need to slough off or be removed by debridement to allow healing. Edema is severe under the eschar and may lead to loss of blood flow or impaired breathing if located on the chest or back. Full thickness wounds are white, gray, or black, and they are painless or nearly so, due to damaged nerve endings.

small pox

The first symptoms of smallpox include high fever (e.g., 101-104 °F [38.3-40 °C]), malaise, head and body aches, and sometimes vomiting. Smallpox may be spread through prolonged face-to-face contact, contact with infected bodily fluids, or contact with contaminated bedding. A person becomes most contagious with the onset of a rash, which starts in the mouth and face and spreads, first as bumps, then pustules and scabs. The infected person is contagious until the last smallpox scab falls off. Standard, contact, and respiratory precautions are required to prevent spread of the disease.

Middle ear trauma

The middle ear is an air-filled cavity between the inner and external ear canal. Causes of middle ear trauma can be classified as direct blunt, penetrating, or barotrauma. Direct blunt and penetrating trauma includes direct force of an object to/in the middle ear. Barotrauma is defined as pressure differences leading to an altered tympanic membrane which can ultimately lead to pain, hearing loss, and injury. Signs and symptoms of middle ear trauma include otorrhea, nystagmus, ataxia, battle sign (bruise behind ear), and hearing loss (demonstrated by Weber and Rinne test). Management of each middle ear trauma varies and is dependent on the cause. All can cause middle ear trauma: Air travel Air travel is a frequently encountered cause of middle ear barotrauma. Scuba diving Scuba diving is a cause of middle ear barotrauma. Blast exposure Blast exposure is a cause of middle ear barotrauma. Q-tip use Q-tip use is a common cause of penetrating middle ear trauma. Motor vehicle collision Motor vehicle collision (MVC) is a cause of direct blunt middle ear trauma.

restraints

The nurse uses restraints only after restraint alternative interventions have failed. After applying restraints, the nurse removes the restraints at least every two hours to reposition and toilet the client, if not sooner. Correct Order: 1. The nurse identifies the correct client is receiving restraints to improve client safety. 2. The nurse inspects both wrists for lines, sores, or deformities. Place restraint with extra care and extra padding if needed to avoid injuries to the wrists from restraints. 3. The nurse applies the restraint snugly, but not tightly to the client's wrist. Restraints applied too tightly may cause neurovascular injury. 4. The nurse inserts two fingers beneath the wrist restraint to ensure it is not applied too tightly. 5. Tie to bed with quick release knot.

Burn pt teaching

This client is at risk of infection and the nurse needs to focus on ensuring the client understands how to properly care for the wounds. To increase the client's motivation and understanding, the nurse will provide additional education, which is individualized to the client's needs and abilities. The teach-back method is an intervention designed to improve health literacy by ensuring clear communication between health care providers and clients. Most clients that are non-compliant do not fully understand the consequences of not following the prescribed treatment plan or may be unable in some way to follow the plan. It is important for the nurse to fully assess the client's ability and motivation and plan care based on those abilities. Teach: Explain wound care and complications in terms the client understands. The nurse assesses the client's educational needs and ability to learn prior to the teaching session so the information may be provided using appropriate materials at the client's cognitve level. Review the dressing change, using the teach-back method. After providing instruction, the nurse uses the teach-back method by asking the client to state the instructions in their own words or, in this case, to demonstrate the dressing change. This ensures that clear instructions have been given and received. Ensure the client has the ability to obtain the dressing supplies. The client may not know where to obtain the needed supplies or may not be able to afford them. The nurse may consult with the social worker if the client has needs in this area. Don't Teach: -Don't: Describe the epidemiology of burn wounds and sepsis. This may sound like a scare tactic and is likely unneccessary. It may cause confusion or argumentativenes. The nurse assesses the client's understanding and challenges before assuming this step is useful. -Don't: Inform the client that the health care provider will not treat someone who is non-compliant. Avoid using the term "non-compliant"; it is not therapeutic, and the client may have been unable to perform the dressing changes due to lack of understanding, or due to inability to obtain or afford supplies.

Tinnitus

Tinnitus is the sense of sound in the absence of an external source. It is often described as a ringing, hissing, or buzzing sound. The degree of tinnitus can vary from acute to chronic and have minimal to significant impact on activities of daily living (ADLs). Tinnitus is more common in men, individuals who smoke, and the older-adult client.

Uveitis

Uveitis is inflammation of the middle eye, also known as the uvea. The uvea is comprised of the iris, ciliary body, and choroid. Treatment is often times urgent and focused on treating the underlying cause (infection vs. no infection). The goal of treatment is to reduce the intraocular inflammation. First line treatment is topical glucocorticoids. Topical glucocorticoids Topical glucocorticoids are first line treatment for uveitis. Oral glucocorticoids Oral glucocorticoids are a second line treatment for uveitis and saved for clients who do not respond to topical steroids. Oral cytotoxic agents Cytotoxic agents or immunosuppressive drugs are second line treatment and only needed in a small percentage of clients diagnosed with uveitis.

Pressure ulcers/injury

Various validated instruments (e.g., the Braden Scale) exist for the measurement and staging of pressure ulcers. It is important that the nurse provides competent skin assessment during client care to identify the client's risk. Because assessment and prevention of pressure ulcers are important nursing priorities, it is imperative that the nurse performs required assessment per recommended guidelines. Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful. Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallow. Stage III pressure ulcers: Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present. Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling. A stage II pressure injury (also called a decubitus ulcer or pressure sore) involves a partial-thickness loss of epidermis or dermis. The skin is not intact, and the wound is superficial, such as an abrasion, blister, or ulcer. Risk factors for skin breakdown include changes in mental status, immobility, altered nutrition or elimination. Wound care includes regular assessment of wound size, depth, color, drainage, and appearance of the surrounding tissue. Necrotic wounds may require debridement. Wound dressings are usually managed by the nurse, with input from the wound nurse. Antibiotics are used only if infection is present. A consistent schedule of turning and positioning the client is instituted, along with dietary measures to enhance the client's nutritional status. Healthcare team to involve for plan of care: Unlicensed assistive personnel (UAP) The UAP will be assigned to turn the client as scheduled and to provide personal care. The UAP should be instructed to notify the nurse of any changes in the client's skin, appetite, or elimination. Dietitian A dietitian can assess the client for caloric needs and recommend a diet to promote wound healing. Wound care nurse A wound nurse is specially trained to assess wounds and recommend specific treatment options. Physical therapist Physical therapy may be involved if the client is prescribed whirlpool therapy for wound debridement. Physical therapy may also assist with devices (such as lifts) to promote mobilization, as immobility is often the cause of sacral ulcers.

skin biopsy

Skin biopsies are performed for diagnosis of a condition or to evaluate the effectiveness of a treatment. Punch biopsy is the most common method, using an instrument that takes a small, circular punch of skin. Local anesthetic is often used. After the biopsy, the site may be sutured or closed with skin adhesive and a bandage applied. The biopsy site should be monitored for bleeding. Incision care includes leaving the dressing intact for at least eight hours, monitoring for infection, and cleaning daily.

Verrucae (warts)

Skin tumors are common and range between benign to malignant. Verrucae is a skin tumor also known as wart and is benign. It is caused by the human papillomavirus virus and occurs more frequently among 12 to 16 year old clients as well as immunocompromised clients. These lesions can be treated by occlusion with duct tape, an evidenced-based procedure introduced in 2007. The use of duct tape allows the skin around the wart to soften and thin, making it easier to remove.

spider angioma (telangiectasia)

Spider angiomas are a form of telangiectasia, or dilated capillary, found on the skin. These lesions are benign and can be removed via laser treatment, with light therapy, or by sclerotherapy.

squamous cell carcinoma (SCC)

Squamous cell carcinomas are characterized by local invasion, slow growth, and infrequent metastasis. They usually present as red nodules with crust or ulceration. They are less common than basal cell carcinomas. Squamous cell carcinomas are characterized by a firm, nodular lesion with crust or an ulcerated central area with indurated margins. Squamous cell carcinoma is characterized by local invasion and deeply invades underlying tissue. Larger tumors are more prone to metastasis.

vocal fold paralysis

Stridor indicates impending loss of airway. Vocal folds protect the airway, enable coughing, and function as a voice. Vocal fold paralysis is a common cause of stridor in infant clients. Some causes of vocal fold paralysis include viral infection, autoimmune disease, birth injury, and mechanical ventilation. Infant clients may present with a low-volume cry, clinical manifestations of aspiration (i.e., recurrent pneumonia and coughing with swallowing), or signs of impending respiratory distress (i.e., stridor). Be most concerned about: High-pitched breath sounds Stridor can be characterized as a high-pitched breath sound. It may present in infant clients with vocal fold paralysis and typically indicates respiratory distress. Not as bad s/s: Low-volume cry A low-volume or weak cry may be present in infant clients with vocal fold paralysis. Recurrent infections Infant clients with vocal fold paralysis may present with clinical manifestations of aspiration such as recurrent infections like pneumonia. Coughing with swallowing Infant clients with vocal fold paralysis may present with clinical manifestations of aspiration such as coughing with swallowing.

Oral Candidiasis (Thrush)

Oral candidiasis is an opportunistic infection. Opportunistic infections are caused by pathogens that take advantage of opportunities from an underperforming immune system such as clients diagnosed with HIV/AIDS and older adults, recently used antibiotics destroying normal flora, are undergoing chemotherapy and/or radiation therapy, or wear dentures where biofilm can grow. True: Undergoing chemotherapy. Oral candidiasis is frequently seen in clients who are undergoing chemotherapy. Diagnosed with AIDS. Oral candidiasis is frequently seen in clients who are immunocompromised (e.g., clients diagnosed with AIDS or HIV). Wears dentures. Oral candidiasis is frequently seen in older adult clients who regularly wear dentures. False: -False: Taking antibiotics for two days. Oral candidiasis is frequently seen in clients who have been taking antibiotics for prolonged periods. -False: Undergoing pelvic radiation. Oral candidiasis is frequently seen in clients who are undergoing radiation to the head or whole body. Oral candidiasis, or thrush, is a common fungal infection. Risk factors include immunosuppression, long-term antibiotic therapy, and infants and older adult clients. Clients develop white patches on the tongue, palate, and buccal mucosa. Oral candidiasis may be painless or may cause severe enough pain that the client is reluctant to eat or drink. Many clients report a change in the way foods taste. It is important for nurses to assess the oral cavity of clients at risk for candidiasis. Treatment begins with topical antifungal therapy, such as Nystatin swish and swallow. Resistant cases may be given systemic antifungal therapy, such as Diflucan (fluconazole). Clients should be instructed to maintain good oral hygiene and avoid use of alcohol-based mouth rinses, which are drying to the mucous membranes and promote cracking and infection. -Oral candidasis is not caused by eating candy or any other food. Questions to ask pt: -"Do the white patches come off easily?" **Oral candidiasis (thrush) is difficult to remove by scraping or brushing. The nurse asks this question to determine if the patches are caused by thrush. -"Are you taking medication to treat cancer?" Oral candidiasis (thrush) is common in clients taking immunosuppressants for cancer, HIV, or organ transplant. -"Have you been taking antibiotics for an infection?" Oral candidiasis can occur in clients taking antibiotics for an extended time due to the removal of normal flora that occurs along with eradication of bacteria.

infectious mononucleosis (mono)

Potentially life-threatening complications include splenic rupture and airway obstruction. Infectious mononucleosis (IM) is an infection caused by the Epstein-Barr virus. It is most commonly seen in adolescents and young adults. Classic clinical manifestations of IM are fever, pharyngitis, tonsillitis, fatigue, and cervical lymphadenopathy. A rash may present if the client takes ampicillin (and sometimes penicillin).

pruritis

Pruritus should be treated based on the pathological cause. If no cause is identified, non-pharmacological interventions aimed at preventing dryness and irritations are primarily used. Itching is often worse at night, so a cool shower before bed followed by application of lotion may be soothing. Herbal teas and oral antihistamines may promote relaxation and relief of itching. Use tepid water and mild, superfatted soap for bathing. Increase fluid intake to 3,000 mL daily if not contraindicated by other conditions. Avoid caffeine and alcohol, which may cause dehydration.

Psoriasis

Psoriasis is a chronic autoimmune skin disease with exacerbations and remissions. Overstimulation of the immune system causes thickened and sore patches of itchy, red skin with silvery or white scales or flakes. These areas often appear on the elbows, knees, scalp, back, palms, feet, and face. Clients with psoriasis may also develop a form of arthritis called psoriatic arthritis, which causes joint pain and swelling. Treatment for psoriasis includes topical applications of corticosteroids such as hydrocortisone and betamethasone, oral retinoids such as acitretin (Soriatane), and UV light therapy. Immunosuppressive drugs such as cyclosporine and methotrexate and injectable biologic medications (tumor necrosis factor-alpha blockers) are used to treat severe psoriasis, but carry serious side effects and risk of infection. Nursing diagnoses for the client with psoriasis may include: Disturbed body image r/t lesions on the body Impaired comfort r/t irritated skin Powerlessness r/t lack of control over condition with frequent exacerbations and remissions Impaired skin integrity r/t lesions on the body Ineffective health maintenance r/t deficient knowledge regarding treatment modalities. Psoriasis is a chronic autoimmune disease that affects the skin and has exacerbations and remissions. Psoriasis cannot be cured, but outbreaks can often be managed with drugs such as topical steroids, topical tar preparations, and UV light therapy. UVB light is aimed at lesions, aiming for gradual tanning of the skin, without redness or pain. Therapy with UVA light (which is not as strong as UVB light) requires administration of a pre-treatment drug, called psoralen, to increase photosensitivity. After taking psoralen, clients must wear dark glasses during the treatment, and for the rest of the day. True: "There is a risk of damage to my skin with UV therapy." Phototoxicity may occur, making the skin red and inflamed. Pain and blistering is possible. If this occurs, therapy is halted and the health care provider is consulted. "Goggles should be worn during UV light treatment." Googles are recommended to decrease UV exposure to the eyes. False: -False: "Using a tanning bed will help my psoriasis." Tanning beds are not recommended as a treatment for psoriasis due to variability of light bulb intensity and to the widespread UV exposure provided. UV therapy for psoriasis is targeted to the psoriatic areas and is monitored closely. Unaffected areas should be covered. -False: "I'll know the treatment is working if the skin looks sunburned." Redness or pain of the skin requires the treatments to be stopped or decreased in frequency or time of exposure to UV light. -False: "Treatment is given on three consecutive days per week." UV therapy is given 2-3 days a week with rest days in between. Receiving treatment on consecutive days will increase the risk of side effects and phototoxicity. Psoriasis treatment includes moisturizers, coal tar, ultraviolet therapy, vitamin D, ointments, retinoids, oral and topical corticosteroids. Researchers found that systemic corticosteroids increase the risk of cardiovascular disease in psoriatic clients. The efficacy of systemic corticosteroids in the treatment of psoriasis warrants further research investigation. -Question if systemic corticosteroids are being prescribed **Systemic corticosteroids are generally not used to treat psoriasis due to side effects and rebound psoriasis. Psoriasis is a chronic inflammatory disease caused by hypersensitivity of the immune system. Division of basal skin cells occurs much more rapidly (4-5 days instead of the normal 28 days), and the build-up of dead cells causes plaque formation. Triggering factors for psoriasis outbreaks include infection, trauma to the skin, hormonal changes, stress, and some medications. Lesions appear as thick, reddened papules or plaques covered with silvery scales. They occur on both sides of the body, most commonly on the scalp, elbows, trunk, knees, sacrum, and outer surfaces of limbs. Lesions rarely occur on the face. Clients may have only a few lesions, or the skin surface may be covered with lesions. Topical treatment includes steroids, tar preparations, and UV light. Resistant psoriasis may be treated with systemic vitamin A derivatives, such as retinoids, and by immunomodulating agents. Psoriasis treatment is not aimed at cure, but at reducing lesions and improving comfort and appearance. True: Presence of lesions of varying sizes Lesions range from 1 to more than 10 centimeters in diameter. Red and scaly lesions Psoriatic lesions are dry and red with white scales. False: -False: Unilateral lesions Psoriatic lesions are disbursed in a symmetrical, bilateral pattern. -False: Thinning of the skin Skin and nail thickening, not thinning, is common in psoriasis. -False: Lesions on the face and neck Lesions occur on scalp, elbows, trunk, knees, sacrum, and outer surfaces of limbs. Psoriatic lesions rarely occur on the face. Psoriasis is a chronic autoimmune disorder that affects the skin and is characterized by remissions and exacerbations. During an exacerbation, increased division of epidermal cells leads to build-up of old skin cells, causing flaky, itchy areas called plaques. Triggers for psoriatic exacerbations vary from person to person, but common triggers include hormonal changes, infection (especially those caused by streptococcus), injury to the skin, and stress. Other precipitating factors include certain medications, smoking, alcohol, and weather. Cold, dry winter air worsens psoriasis, while sunlight will usually help psoriasis plaques fade. UV therapy is sometimes used as a treatment for psoriasis. Other treatments include topical steroids and tar preparations. Psoriasis that does not respond to topical treatment may be treated with systemic immunomodulating drugs. Triggers: Hormone fluctuations Hormone fluctuations can affect psoriasis. Symptoms frequently improve during pregnancy. Infection Infections, both bacterial and viral, can aggravate psoriasis. Injury to the skin Any trauma to the skin including a nick from a razor can trigger psoriatic plaques to develop. Not triggers: High sugar consumption Sugar consumption is not associated with psoriasis exacerbation. Physical activity Physical activity is not associated with psoriasis exacerbation The nurse encourages the client to modify lifestyle, as possible, to diminish the severity of psoriasis. Lifestyle modifications include exposure to some sunlight, washing skin with mild soaps, avoiding infections, decreasing stress, and avoiding alcohol, smoking, and obesity.

cellulitis

Cellulitis is a skin infection that extends into the dermis and subcutaneous tissue. The typical signs of cellulitis are an area of skin that is red, warm, tender or painful, swollen, and with a glossy appearance. Fever may be present. Cellulitis is commonly found on the lower extremities and in areas of skin trauma such as abrasions and puncture wounds, although it may occur in areas with intact skin. Treatment includes antibiotics, most commonly penicillins and cephalosporins. Expect: Swollen, glossy skin The swelling and redness that occur with cellulitis cause the skin to have a glossy appearance. Tenderness in the right groin area. Lymphadenopathy is common in cellulitis and occurs in lymph glands proximal to the injury. Red skin that is hot to the touch. Reddened, warm skin is a common sign of cellulitis. Not common: Itchy rash Cellulitis is not commonly itchy. Grouped vesicles that may weep. Grouped vesicles are seen in herpes infections, not cellulitis. Cellulitis is inflammation of both the skin and subcutaneous tissue that spreads beyond the affected area. Streptococcus pyogenes Cellulitis is most commonly caused by Streptococcus pyogenes, which can also cause strep throat, rheumatic fever, necrotizing fasciitis, and glomerulonephritis.

burn-related inhalation injury

Clients with inhalation injury are at risk for respiratory problems. Nurses should expect inhalation injury in clients with burns on the face, singed eyelashes or nasal hairs, clients who were unconscious at the time of the injury, and clients that are hoarse or coughing. Nursing interventions include airway maintenance, promoting ventilation, monitoring gas exchange, oxygen therapy, drug therapy, positioning, and deep breathing. Interventions: Providing chest physiotherapy Chest physiotherapy may be helpful to mobilize lung secretions. Using humidified oxygen Humidified oxygen should be used to prevent drying of nasal mucosa and secretions. Preparing the client for bronchoscopy Clients with inhalation injury may undergo bronchoscopy on admission and regularly thereafter to assess the airway and allow for deep suctioning and removal of necrotic slough tissue. Suctioning the client's airway Airway suctioning is often needed with inhalation injury if the client cannot cough effectively to clear secretions. Endotracheal or nasotracheal suctioning is performed after chest physiotherapy. Physical findings indicative of inhalation injury include singed nasal hair or oral mucosal burns, soot in the sputum, facial and neck burns. Hoarseness, brassy cough, wheezing, stridor, and use of accessory muscles are also indicators of inhalation injury. Nurses should apply humidified oxygen, position the client in high Fowler's, and prepare the client for possible intubation. Expected in burn inhalation injury: Audible stridor Stridor indicates obstruction of the airway and is a sign of possible inhalation injury. The nurse immediately prepares the client for intubation to protect the airway. Facial burns Facial burns are indicative of inhalation injury. Singed nasal hair Singed nasal hair is indicative of inhalation injury. Not expected: Blood-tinged sputum Sputum is usually black from carbon, not red-tinged. Heart rate 112 beats/min. Tachycardia often occurs with burn injury but is not specific to inhalation injury.

older adult changes

Common physical changes with advanced age include: loss of skin elasticity; thinning hair; decreased cough reflex; increased airway resistance; lower cardiac output; increased systolic blood pressure; decrease in saliva, digestive enzymes, and pancreatic enzymes; decreased muscle mass and strength; decreased speed of nerve conduction impulses; presbyopia; thickening of ocular lens; decreased pupil size; dry eyes; presbycusis; diminished taste sensation; decreased bladder capacity; and lowering of core body temperature. Not common, report: Reddened sclera Reddened sclera is abnormal for all ages and may indicate infection, closed angle glaucoma, or the presence of a foreign body. A resting tremor A resting tremor may indicate Parkinson disease, particularly if it is unilateral or isolated to the leg, voice, or chin. A back-and-forth rubbing of the thumb and forefinger is known as a "pill-roll" tremor and is associated with Parkinson disease, tardive dyskinesia, and other disorders. This may be noted in benign conditions such as essential tremor, also.

contact dermatitis

Contact dermatitis is an inflammatory response to an irritant or allergen such as harsh soaps, chemicals, poison ivy, and metals such as nickel. Skin eruptions appear red, with well-defined margins that correspond to the area of contact with the irritant or allergen. Vesicles and papules may develop, especially with plant allergies such as poison ivy. Avoidance of the irritant is key to treatment. Topical or systemic corticosteroids may be used if itching is severe, but topical medications should not be used with non-intact skin. -Irritants such as harsh soap cause a toxic injury to the skin, resulting in redness that is localized to the areas of contact with the irritant. Contact dermatitis is a rash that results after coming into contact with an irritant or allergen. Irritants cause a toxic injury to the skin, and allergens cause a cell-mediated immune reaction. Skin appears red and inflamed in a well-defined area and may exhibit vesicles or papules in a linear pattern if caused by a plant allergy, such as poison ivy. Treatment involves avoidance of the irritant and comfort measures, such as cool compresses, use of topical corticosteroids, and oral antihistamines. Oral corticosteroids in a tapering dose may be prescribed if the rash is widespread or severe. Reduce burning/pruritis: "Use over-the-counter (OTC) oral antihistamines as directed." Antihistamines may reduce the itching of dermatitis, but they do have a sedative effect and should not be taken more frequently than directed. "Apply a thin coating of prescribed corticosteroid cream twice daily." Corticosteroid creams may be prescribed and should be applied in a thin, even layer. Caution the client not to use corticosteroids more than prescribed. "Use cool, wet dressings as needed." Cool, damp compresses may reduce itching and burning. Don't: "Take a hot shower or bath once or twice daily." Bathing should be done with warm or cool, not hot, water. Hot water is drying to the skin and can increase itchiness. Bathing more than once daily will also increase skin dryness. "Wash the area frequently with soap." Soap promotes drying of the skin and will increase itching.

retinal detachment

Dehydration in older adults is common due to decreased renal function. Older clients often have a diminished thirst sensation or may decrease their fluid intake if they are experiencing poor bladder control. Nurses should explain risk factors associated with dehydration. Signs of dehydration include dry skin, lethargy, dizziness, poor skin turgor, concentrated urine, and dry mouth with cracked lips. The tongue may appear slightly cracked.

Wet-to-dry dressing

For Diabetic Foot Ulcer Wet-to-dry dressings is used for the mechanical debridement of exudate and necrotic tissue. They also promote wound healing from the inside-out. Debridement of necrotic tissue Wet-to-dry dressings aid in debridement of necrotic tissue. Wound debridement of exudate Wet-to-dry dressings aid in debridement of exudate Minimize trauma to healing tissue Wet-to-dry dressings promote wound healing by minimizing trauma to healing tissue. Hydrocolloid dressing: Prevent contamination of microbes Hydrocolloid dressings minimize discomfort and prevent contamination of microbes. Minimize wound discomfort Hydrocolloid dressings minimize discomfort and prevent contamination of microbes. Wet-to-moist dressings provide debridement, usually for ulcers or soft tissue wounds. Depending on the type of ulcer and the client's level of sensation, this dressing may be quite painful.

Frostbite

Frostbite results from exposure to extremely cold temperatures. Frostbite causes bodily injury, resulting in loss of feeling or sensation and color in the affected areas. Severe frostbite causes the muscles, tendons, vessels, and nerves to freeze, with the skin becoming hard and waxy. Freezing of blood vessels causes decreased exudate and perfusion. Purple or black blisters occur in the affected areas.

Hand-foot-mouth disease (HFMD)

Hand, foot, and mouth disease (HFMD) is generally a mild childhood illness. Clinical manifestations include an exanthem, low-grade fever, oral lesions, and lack of gastrointestinal symptoms. HFMD is treated at home with supportive care. It is imperative for the caregivers to closely monitor the child's oral intake. If the child is refusing to eat and drink due to mouth/throat pain and showing signs of dehydration (decreased urine output or lethargy,), they must be immediately brought to the emergency department for rehydration via IV fluid therapy.

Rule of 9's for burns

Head = 9% Arms = 18% (9% each) Back = 18%, Front/chest/trunk 18% Legs 36% (18% each) Genitalia = 1 Using the rule of nines, nurses can estimate the percentage of BSA affected.• Anterior torso 18%• Anterior leg, each 9% (18%)• Anterior arm, each 4.5% (9%)In addition, the front and back of the head account for 4.5% each.

Ventilator-associated pneumonia (VAP)

Health care-associated infections (HAIs) are infections acquired in a health care setting as a result of client-provided care. Ventilator-associated pneumonia (VAP) is a type of HAI; it is a lung infection that occurs in a client who is on a ventilator. Oral care provided by the nurse plays a crucial role in the prevention of VAP. The Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee recommend regular oral hygiene with a toothbrush (or gauze if no teeth) and an antiseptic agent for all clients who are on a ventilator. Other preventative measures for VAP include elevated head of the bed, hand hygiene, and proper weaning techniques. Other protocols in the ICU include delirium prevention by allowing rest and use of compression devices and anti-thrombotic agents to reduce occurrence of DVT and PE.

Herpes simplex virus type 1 (HSV-1)

Herpes simplex virus (HSV) is a common infection and is classified as type 1 (HSV-1) or type 2 (HSV-2). Oral lesions are typically caused by HSV-1, whereas genital lesions are most likely caused by HSV-2. HSV is highly transmittable and can be spread through direct contact with the lesions or oral secretions. Proper hand hygiene and avoidance of precipitating factors (if possible) are essential aspects of disease prevention. Factors: Recent divorce Emotional stress is a precipitating factor for herpes simplex virus (HSV). Death of spouse A traumatic event is a precipitating factor for herpes simplex virus (HSV). False: -False: Vitamin D deficiency Sun exposure, not vitamin D deficiency, is a precipitating factor for herpes simplex virus (HSV). -False: Dental cleaning Stressful events a precipitate herpes simplex virus (HSV). A dental cleaning is not typically considered stressful. -False: Menopause Menstruation, not menopause, is a precipitating factor for herpes simplex virus (HSV).

hyperbaric oxygen therapy (HBO)

Hyperbaric oxygen therapy increases oxygenation to compromised tissue, such as wounds and burns. Increasing the oxygen supply to the affected tissues aids in wound healing. Few high-quality studies have been conducted using HBO therapy, and so there is little data to prove its effectiveness. Most often HBO therapy is used with non-healing or chronic wounds as an adjunct to antibiotics and surgical debridement. Complications from HBO therapy are rare but include seizures and pneumothorax. True: "I will be able to stay home with HBO therapy, instead of being in the hospital." Portable HBO chambers are available in some areas, allowing the client to receive treatment at home. "Even though I'm getting the HBO therapy, I will still have to take antibiotics for for several weeks." Osteomyelitis requires weeks or months of antibiotic therapy. HBO therapy is used as an adjunct to antibiotic therapy, and there is not yet sufficient research to prove that HBO treatment reduces healing time in chronic wounds. "I will need to stay in the HBO chamber for two hours every day." HBO therapy is prescribed for 1.5 to 2 hours daily for 20 to 40 days. False: -False: "I'm glad I chose to have HBO therapy instead of surgery." HBO therapy is used as an adjunct to high-dose antibiotics and surgical debridement, not as a stand-alone treatment.

Braden Scale

In the Braden scale, there are six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Sensory perception is scored from completely limited-1, very limited-2, slightly limited-3, and no impairment-4. Moisture is scored from constantly moist-1, often moist-2, occasionally moist-3, and rarely moist-4. Activity is scored from bedfast-1, chairfast-2, walks occasionally-3, and walks frequently-4. Mobility is scored from completely immobile-1, very limited-2, slightly limited-3, and no limitations-4. Nutrition is scored from very poor-1, probably inadequate-2, adequate-3, and excellent-4. Friction and shear is scored from problem-1, potential problem-2, and no apparent problem-3. Mild risk A score of 15 or above indicates mild risk for pressure ulcer development. Moderate risk A score of 13-14 indicates moderate risk. High risk A score of 10-12 indicates a high risk for pressure ulcer development. Severe risk A score of 9 or less indicates a severe risk for pressure ulcer development. The Braden scale is used to predict pressure ulcer risk. In the Braden scale, there are six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Scores range from 6-23: a score of 15-18 indicates a mild risk for pressure ulcer formation, 12-14 indicates moderate risk, and less than 11 indicates severe risk.

Informed consent

Informed consent is the client's agreement to have a medical procedure, after the health care provider has explained the risks, benefits, alternatives, and consequences of refusal. Common risks and benefits, alternatives, and plan for treatment are discussed. The nurse's signature to the consent indicates that the client voluntarily gave consent, that the signature is authentic, and that the client appears to be cognitively capable of making decisions. Statements that indicate informed consent has not been obtained: "Are there other treatment options?" Treatment options are discussed as part of informed consent, so this question shows that the client is not fully informed. "It sounds scary, but I know I'm completely safe." All procedures have risks, so this statement indicates the client is not informed.

Malignant melanoma

Malignant melanomas are the least common type of skin cancer and the most deadly. They appear black or brown with irregular borders and often metastasize. Risk factors include fair skin, history of sunburns, family history, and having many moles. Survival rates improve with early detection and treatment. Surgery to remove the melanoma is necessary, often followed by topical chemotherapy. "Use sunscreen and limit sun exposure." Sun exposure increases risk of melanoma. Clients should limit exposure to prevent further skin cancer development. Malignant melanomas appear black, blue, or brown with irregular borders. They are usually asymmetrical, large, and evolving. Malignant lesions present with the signs of malignant skin lesions based on the A, B, C, D, E system. Based on this system the lesions may appear asymmetrical with irregular borders. They can appear with multiple colors with diameter measuring greater than 1/4 inch. The lesions evolve in size, shape, and color, compared to benign moles that tend to be circular, flat, brown, and uniform. Characteristics of melanoma that require follow-up: The lesion is almost a centimeter wide. The typical size of a melanoma lesion is greater than 1/4 inch (1 cm is just less than a 1/2 inch), or the size of a pencil eraser. The client states, "It's grown lately." This is a general statement from the client and would require additional action to verify whether the lesion is a melanoma. The lesion has a raised, irregular border. Melanoma is identified by an irregular, raised border that may appear like a mole. Don't: The lesion is dark brown. Moles may be various colors including brown, so this is not indicative of melanoma, as it could be representative of a benign mole or lesion. The lesion is flat and round. Melanoma is identified by an irregular, raised border so a flat lesion is not indicative of melanoma. A round, symmetrical lesion does not meet the criteria for a melanoma lesion.

Carbon Monoxoide Poisoning

Nonsmokers can have carbon monoxide levels ranging from 0-5%. Smokers can have levels as high as 15%. Levels greater than 15% are considered carbon monoxide toxicity. A client with a level of 20-30% may experience headaches, nausea, vomiting, or confusion. A client with a level of 31-40% may experience dizziness, vision problems, tachycardia, tachypnea, or hypotension. A client with a level of 41-50% may lose consciousness. A client with a level above 50% may experience seizures, coma, or even death. Carbon Monoxide (CO) poisoning is the leading cause of death that results from fires. During combustion, it is an odorless, colorless gas that is emitted. Inhalation injury is likely to occur as a result of CO poisoning. CO poisoning may also occur in smokers and nonsmokers. Nonsmokers can have carbon monoxide levels ranging from 0-5%, smokers can have levels as high as 15%. Levels greater than 15% are considered carbon monoxide toxicity. 20-30% - Headaches, nausea, vomiting, confusion 31-40% - Dizziness, vision problems, tachycardia, tachypnea, hypotension 41-50% - Loss of consciousness 50% - Seizures, coma, death

Home safety for visually impaired

According to the Centers for Disease Control and Prevention (CDC), older adults who are visually impaired are significantly more likely to fall than those without visual impairments. It is imperative for nurses and health care professionals to educate clients, especially those with risk factors or impairments, on home safety measures. Some safety measures directed towards fall prevention in the home include ensuring walking areas are brightly lit, removing throw rugs, clearing all walkways, labeling cleaning and toxic products, and using contrasting handrails. Needs teaching when they state: "I will use solid wood handrails on stairs." Contrasting handrails are handrails that are bright in color (i.e., red, orange, yellow), rather than solid wood. This provides an easier visibility and safer walk up and down the stairs and is particularly useful for the client who is visually impaired. .

Acne vulgaris

Acne vulgaris is the most common skin condition. The precise cause is unknown, although heredity, stress, drug reactions, hormones, and bacterial infections are thought to contribute to acne breakouts. Increased oil secretion from the skin combined with overgrowth of the follicular surface and the presence of bacteria contribute to acne. Acne lesions include open or closed comedones (blackheads and whiteheads), pustules, papules, and nodules. Lesions are usually found on the areas of the body with the largest hormonally-responsive sebaceous glands such as the face, neck, chest, upper back, and upper arms. Acne eruptions typically begin in puberty and continue through young adulthood. Acne vulgaris is a skin condition causing pimples to develop. It is the most common skin disorder in North America. Clients should avoid cosmetics or hair products that contain oil. They should also avoid frequent or aggressive scrubbing of the face. It is not clear if diet affects acne outbreaks, but a weak association has been found between acne and cow's milk. Stress can exacerbate acne. "Use skin products labeled noncomedogenic." A comedo is a blackhead. Noncomedogenic means the product will not clog pores. Clogged pores cause blackheads. Pharmacologic treatment for acne includes topical retinoids, benzoyl peroxide, and antibiotics for mild to moderate acne. Moderate to severe acne treatment includes oral antibiotics such as doxycycline and oral isotretinoin. Isotretinoin has been classified as pregnancy category "X", meaning it can cause miscarriage and life-threatening malformations in the baby. Pregnancy testing is conducted before starting therapy with isotretinoin, and monthly during treatment. -Isotretinoin cures or significantly improves acne in most clients Intervention required if clients states: -"My boyfriend takes care of birth control for us." Clients taking isotretinoin must utilize two forms of birth control. The client needs to be actively involved in ensuring she cannot become pregnant while taking this drug. The nurse must intervene to ensure the client understands this. -"If this medication doesn't work, I don't know what I'll do." Isotretinoin has been linked to depression and suicide. Clients should notify their provider of any feelings of sadness, depression, or anxiety. This statement indicates hopelessness, and the nurse should ensure the health care provider is notified. Primary lesions present with acne include papules, pustules, nodules, and cysts. Papules are solid elevated lesions not containing fluid. Pustules are small elevated lesions containing pus. Nodules are small palpable, firm lesions. Cysts are raised, encapsulated lesions filled with fluid. Macules are flat areas of altered color or texture, such as a freckle. Bullas are blisters. Lesions: Open comedones Open comedones are non-inflammatory lesions seen in acne vulgaris. They are also known as "blackheads." Closed comedones Closed comedones are non-inflammatory lesions seen in acne vulgaris. They are also known as "whiteheads." Papules Papules are inflammatory lesions seen in acne vulgaris and are most commonly seen on the face, neck, and upper back. Pustules Pustules are inflammatory lesions seen in acne vulgaris and are most commonly seen on the face, neck and upper back.

age-related macular degeneration

Age-related macular degeneration (AMD) is degenerative disease of the retina. It can be classified as dry (atrophic) or wet (exudative). AMD is the leading cause of legal blindness in adults who live in industrialized countries (i.e., the United States and other Western European countries). Other common causes of visual impairments in adults are cataract, glaucoma, diabetic retinopathy, and presbyopia (farsightedness).

Skin graph/autograph

An autograft is a skin graft taken from an undamaged part of the client's skin and transplanted to the injured area where the dead skin has been removed. Once the dressing has been removed, monitor the graft site for signs of failure to vascularize, such as dusky color, or necrosis. The nurse also monitors for signs of infection, such as fever, foul drainage, or elevations in white blood count. Improve skin graph outcomes: Immobilize the left arm. Skin graft sites should be immobilized to promote adherence and healing for the first 3-7 days. Maintain gauze dressing over autograft for 3-5 days. A bulky gauze dressing will be placed in surgery, and the nurse should leave that dressing in place to promote adherence. If bleeding or drainage shows on the outside of the dressing, it may be reinforced with more gauze. Range of motion activities are delayed until graft adherence has been established.

escharotomy

An escharotomy is an incision through the eschar (dead tissue, usually from burns). The affected area or extremity is incised to relieve pressure caused by edema. The depth of the incision is limited to the eschar tissue. The desired outcome of an escharotomy is to improve circulation to the area of eschar tissue. As a result of the escharotomy, edema may decrease in the area beneath the eschar. -Return of circulation distal to the burn Escharotomies performed on circumferential burns restore circulation to the extremities.

Scabies

Scabies is a parasitic skin infection that presents as red papules/pustules with brown, thread-like, linear burrows. Anti-scabies creams and medications should be applied to dry skin to reduce the risk of systemic absorption and side effects. Most eruptions in children under two years old appear on the feet or ankles. Scabies can easily spread from person to person. Therefore, all members of the household should be treated. All clothes and linens should be washed in hot water and dried with hot air. Scabies may appear like eczematous eruptions on the skin of infants, so the nurse should observe for discrete papule, vesicles, or burrows. Scabies is a parasitic skin infection that presents as red papules or pustules with brown, thread-like linear burrows. Scabies medications should be applied to dry skin to reduce the risk of systemic absorption and side effects. Most eruptions in children under two years old appear on the feet or ankles. Scabies can easily spread from person to person. Therefore, all members of the household should be treated. All clothes and linens should be washed in hot water and dried with hot air.

Sialolithiasis

Sialolithiasis is a disorder where stones develop within the salivary gland ducts. The stones can be found in the parotid, submandibular (most common), and sublingual salivary glands. Risk factors for developing salivary gland stones include smoking, chronic periodontal disease, history of nephrolithiasis, certain drug use (i.e., anticholinergics and diuretics), dehydration, gout, hypovolemia, and trauma. Clinical manifestations are pain and swelling with food intake.

Cataract

A cataract is defined as lens opacity that can lead to blurred vision, glare issues, and even blindness (in extreme cases). Cataracts can be prevented by limiting exposure to the sun and ultraviolet B (UVB) rays, smoking cessation, avoiding exposure to lead, exercising regularly, and eating a health diet. Other risk factors for developing cataracts include age, metabolic syndrome, corticosteroid use (systemic and prolonged high-dose inhaled). Treatment for cataract includes removing and replacing the lens. Surgery is considered safe with few associated complications. It is typically an outpatient surgery. Post-operative surgical care instructions include resuming all normal activities and oral medications. Mild, not severe, pain can be expected for the first few days after surgery. An eye patch may be worn, depending on the type of anesthesia used. Most clients are seen for an initial follow-up appointment 1 week after surgery.

herpes zoster (shingles)

Herpes zoster is the infection caused by reactivation of the varicella zoster virus (VZV) in persons who have previously had chickenpox. The dormant virus resides in sensory nerves until reactivated. Lesions cause irritation and pain prior to eruption, then become pruritic. Multiple lesions occur in an area innervated by the infected nerve. In older clients, post-herpetic neuralgia is common. The diagnosis of shingles is generally that of clinical presentation. Routine lab work is not required for the diagnosis, but in cases where the rash is atypical, confirmation by DFA testing may be performed quickly and inexpensively. Direct fluorescent antibody (DFA) test -Rapid diagnosis of herpes zoster can be achieved by DFA testing on scrapings from active lesions that have not yet crusted. Herpes zoster, also known shingles or zoster, is caused by the reactivation of the varicella-zoster virus (VZV) which also causes chickenpox. Primary infection with VZV causes varicella (chickenpox). Once the illness resolves, the virus remains dormant in the dorsal root ganglia and may reactivate years later, causing a painful, maculopapular rash called herpes zoster. VZV is spread by direct contact with the rash or lesions. A person with no prior exposure or immunity to VZV are most likely to develop varicella zoster (chickenpox), not herpes zoster (shingles). A person is not infectious before the appearance of lesions. Only people who had natural infection with wild-type VZV (chickenpox) or had the varicella vaccination can develop herpes zoster. Many people do not remember having varicella, but approximately 99% of people born in the United States over age 40 have been infected with wild-type VZV. In those who have already had a natural exposure or vaccination, exposure to VZV does not cause shingles. Instead, the dormant virus may be reactivated later in life as cell-mediated immunity declines or by stress or illness. The zoster vaccine (Zostavax) is recommended for people aged 60 years and older. Even those who have had herpes zoster (shingles) should receive the vaccine to help prevent future occurrences of the disease. The vaccines has only a five-year efficacy. Shingles result after chickenpox has resolved and the virus becomes latent near the spinal cord in the peripheral nervous system. When the virus becomes active, normally during illness or stress, it travels down the axon, causing a rash in the nerve's corresponding dermatome. Lesion pattern: -Dermatomal Shingles presents as vesicles along dermatomal lines, usually on the trunk, thorax, or face.

Prevention of immobility complications

Immobility puts the client at risk for development of pressure ulcers. Adequate nutrition and hydration are essential for the prevention and treatment of pressure ulcers. Fluid intake should be between 2,000 and 3,000 mL daily. Sedated or bed-bound clients should be assisted with self-care or given bed baths daily. Avoid hot water and use a pH balanced skin cleanser. Maintain skin hydration by applying lubricating moisturizers and creams with minimal alcohol content. Use protective barriers (e.g., skin protectant cream, transparent films, hydrocolloids) to reduce friction injuries. Other interventions include repositioning at least every two hours, use of devices to relieve pressure on the heels and bony prominences of the feet, and turning the client 30 degrees to either side to avoid pressure on the trochanter. Shearing forces may be reduced by keeping the head of the bed at 30 degrees or lower and by using transfer or lifting devices to avoid dragging patients on the bed sheets. Bathe with mild cleanser. Immobile clients require assistance with bathing. Avoid hot water as it is drying to the skin, and use a pH balanced skin cleanser. Provide supplemental nutrition. To avoid skin breakdown, nutritional supplementation may be needed if the client is not taking in enough nutrients. Monitior for a low serum albumin level, as albumin and pre-albumin levels are reliable indicators of nutritional status. Turn the client every 1-2 hours. The client should be repositioned at least every two hours, and more often if the condition warrants. Don't: Avoid the use of lotions. Moisturizer or skin protectant creams should be applied after bathing. Dry skin is more susceptible to shearing, abrasion, or tears. Keep the head of bed at 45 degrees. Shearing forces may be reduced by keeping the head of the bed at 30 degrees or lower if the client's medical condition allows.

impetigo

Impetigo most commonly occurs on the face, around the nose and mouth, or on the hands and feet. Impetigo is a bacterial skin infection that produces vesicles or pustules. The lesions are edematous and red, often producing exudate that crusts. Impetigo occurs most often in children, and during warm, humid weather. Treatment for impetigo includes topical antibiotic cream, or in more severe infections, oral systemic antibiotics may be prescribed. Good handwashing and not sharing towels prevents the spread of infection. Impetigo is a bacterial skin infection that is very contagious and is generally caused by staph or strep infections. It is transmitted by direct contact. Red raised papules eventually dry and scab over with a brown, gold, or yellow crust. Lesions are treated by cleansing gently with wet cloth to loosen crusts, patting dry, and applying topical antibiotic ointment. More involved infections may require systemic antibiotics. Prevent transmission: Use separate linens and towels from other members of your household. Use separate linens and towels from other persons, launder in hot water, and dry on high heat. Do not eat or drink from the same dishes or glassware as others, and wash the dishes in hot, soapy water. Keep your fingernails clipped short. Impetigo is often intensely pruritic and scratching should be minimized. Keeping fingernails short will reduce spread of the infection to other body parts and persons. Wash your hands frequently with soap and warm water. Handwashing is the best way to prevent the spread of infection. Don't: Keep the lesion covered with an occlusive bandage. Lesions should be allowed to dry from air exposure, so an occlusive dressing should not be used. To prevent spread from scratching, lesions may be covered with a gauze dressing. Shampoo and condition your hair daily. Daily shampooing is not helpful in preventing transmission of impetigo.

Burns priority needs

Nurses classify client problems as high, intermediate, or low priority. High-priority problems, if left untreated, pose an immediate danger to the client. Intermediate priority problems include the non-emergent, non-life-threatening needs of clients. Low-priority needs include problems of well-being, either current or future. The ABCs (airway, breathing, and circulation) and Maslow's hierarchy of needs help nurses determine the priority of problems. Prioritization changes as the client's condition changes. Correct Order: Ineffective breathing pattern related to tissue trauma Acute pain related to tissue trauma Risk for infection related to trauma Disturbed body image related to scarring During the first 24 hours of a burn, the client is at risk of respiratory and circulatory failure. In the 24-72 hour period, this threat persists, and is managed appropriately. This means that airway and breathing are managed, then circulation, including electrolyte and fluid management, and finally, pain and nutrition management. 72 hours after admission, correct order: Assessment is first, unless required assessments have already been obtained. Airway and breathing is first, unless it is not relevant of sufficient data is already available. The client 24 - 72 hours post-burn has typically been fluid resuscitated and is at continued risk of pulmonary edema. Adequate urine output is the best indicator of circulatory status. On a recently burned client, UOP is evaluated every 1-2 hours, even if the client has been urinating adeqately. An indwelling catheter and collection bag is used during this period to provide accuracy. Many lab values are important in this case, but electrolyte balance is essential. The post-burn client is at continued risk for electrolyte imbalances, especially potassium, and therefore is at risk of circulation impairment. Evaluating electrolytes frequently can help prevent arrhythmia complications. The client's wounds need to be covered to prevent infection and to promote warmth, thereby maintaining a desired metabolic rate. However, this is not an immediate threat to airway, breathing, or circulation, and is the last priority. The emergency management of burns within the first few hours is critical in saving a client's life. The key focus for a severely burned client is to ensure a patent airway with effective breathing, limit further progression of injuries, ensure adequate circulation, and protect vital organs. Specific management of burns depends on the type of burn, such as chemical or flame burns.

A client who is hard-of-hearing is being discharged home. The nurse performs discharge teaching and is required by law to perform which additional action?

Offer language assistance services. The nurse is required to provide language assistance services to all clients who are hard-of-hearing, deaf, or have limited English proficiency (LEP). It is essential for the nurse to provide language access services to clients who are deaf, hard-of-hearing, or LEP. The federal civil rights laws protect this client population by requiring health care providers to offer language access services to facilitate and ensure effective communication. These services include, but are not limited to, qualified interpreters, transcription services (computer-aided), written handouts, and note takers.The nurse should never assume the interpreter is competent in medical terminology, confidentiality, or equality. Doing so can lead to misinterpretations. All services offered should be free of charge.

Glaucoma

Primary angle-closure (PAC) glaucoma is a type of closed angle glaucoma. It is a primary glaucoma and includes acute-closure and chronic angle-closure glaucoma. Drainage angles of the eye in patients with PAC are narrow. After pressure is stabilized, treatment includes laser peripheral iridotomy. Drugs that have the potential to cause pupillary dilation should be avoided, until this procedure is undergone, to reduce the risk of inducing an angle-closure attack. These drugs include antipsychotics, adrenergic agents, decongestants, anticholinergic agents, methamphetamines, and antidepressants. Don't give: Haloperidol Haloperidol is a first generation antipsychotic used to treat schizophrenia. Antipsychotics should be avoided in clients diagnosed with primary angle-closure glaucoma who have not undergone laser peripheral iridotomy. Methamphetamine Methamphetamine is a central nervous stimulant commonly used for clients with ADHD. Methamphetamines should be avoided in clients diagnosed with primary angle-closure who have not undergone laser peripheral iridotomy. Pseudoephedrine Pseudoephedrine is a decongestant commonly used to treat upper respiratory infections and sinusitis. Decongestants should be avoided in clients diagnosed with primary angle-closure who have not undergone laser peripheral iridotomy. Scopolamine Scopolamine is an anticholinergic agent used for motion sickness and as a preoperative antiemetic. Anticholinergic agents should be avoided in clients diagnosed with primary angle-closure who have not undergone laser peripheral iridotomy. Amitriptyline Amitriptyline is a tricyclic antidepressant used to treat depression. Antidepressants should be avoided in clients diagnosed with primary angle-closure who have not undergone laser peripheral iridotomy. Glaucoma is defined as an increase in IOP. It is classified as acute, subacute, and chronic. Chronic glaucoma is consistent with a slow rise in IOP and often times the client lacks symptoms; whereas acute angle-closure glaucoma leads to a rapid rise in IOP. Symptoms of acute glaucoma include headache, nausea and/or vomiting, photophobia, decreased vision, eye pain, and halos around lights. Upon examination that client will have a red eye and may have a hazy cornea. Acute angle-closure glaucoma is a medical emergency and must be treated within hours to preserve the optic nerve and sight. Open-angle glaucoma (OAG) is defined as optic neuropathy. It initially presents as visual field loss, and if left untreated can lead to permanent blindness. Risk factors for OAG include age, race, family history, increased intraocular pressure, cardiovascular disease (i.e., hypertension), hypothyroidism, and myopia. Nurses play a significant role when it comes to preventative health care. The three level of prevention are primary (health promotion and prevention of the onset of disease), secondary (early identification of disease through screenings and regular care), and tertiary (treatment of disease post diagnosis). -Primary prevention: "Lifestyle modifications should be made to prevent cardiovascular disease." Cardiovascular disease, including hypertension, is a risk factor for developing open-angle glaucoma. Making lifestyle modifications, such as diet and exercise, is a primary preventative measure that is significant in reducing the risk of developing this disease.

tonsillectomy

Primary hemorrhage, oropharyngeal bleeding, is bleeding that occurs less than 6 hours after surgery. Signs of bleeding after a tonsillectomy include: Bright red blood coming from the mouth or nose Tasting blood —a metallic taste Frequent swallowing Spitting out bright red blood Vomiting bright red or old blood A tonsillectomy is the surgical removal of one's tonsils. Indications for a tonsillectomy include chronic or recurrent infection of the tonsils (tonsillitis), obstructive sleep apnea (OSA), and recurrent throat infections (pharyngitis). Post-tonsillectomy complications include hemorrhage, infection (tonsillar bed or pneumonia), and pulmonary complications (i.e., pulmonary edema). Post-operative care includes management of pain and nausea/vomiting, adhering to an appropriate diet, and monitoring for bleeding and vital signs.