Med Surg - Assessment of Integumentary System ch 22

lesion distribution generalized

diffuse distribution

Clark level method of tumor thinkness measurnment

indicates the depth of invasion of the tumor; the higher the number, the deeper the melanoma.

Nevus of Ota

slate-gray or blue-gray birthmark located on the forehead and face around the eye area

Nonmelanoma Skin Cancers Actinic keratosis

Premalignant skin lesions

Assess skin temperature using your hand.

An ulceration may feel warm initially, then become cooler.

Assessment of Patients with Dark Skin

Touch the skin to feel its consistency. Boggy or edematous tissue may indicate a stage I pressure ulcer. Ask about pain or an itchy sensation

NPO status is usually

6-8 hours for general anesthesia; 3 hrs with local.

Topical medications:

A thin layer of ointment, cream, lotion or solution, or gel should be applied to clean skin and spread evenly in a downward motion. Thickly applied topical medications waste medication and leave the skin greasy. An alternative method is for you to apply the medication directly onto a dressing.

When examining the skin of an 80-year-old patient, the presence of which lesions will be of most concern to the nurse? Varicosities Cherry angiomas Actinic keratoses Seborrheic keratoses

Actinic keratoses are premalignant cutaneous lesions. The risk for squamous cell and basal cell carcinomas is increased.

assessment areas for darker skin people

Assessment of color is more easily made in areas where the epidermis is thin and pigmentation is not influenced by sun exposure, such as the lips, mucous membranes, nail beds, and protected areas (e.g. buttocks).

skin health promotion/teaching points

Avoidance of environmental hazards Adequate hygiene and nutrition Skin self-examination

Preoperative client teaching

Inform client that requesting opioid medications (narcotics) postoperatively will not make him or her a drug addict Instruct in deep-breathing and coughing techniques, use of incentive spirometer, importance of completing these techniques as instructed Explain any invasive equipment that will be present after surgery (NG, chest tubes, ETT etc.)

Stage one pressure ulcer

Intact skin with non-blanchable redness Possible indicators—skin temperature, tissue consistency, pain

Stage 4 pressure ulcer

Full-thickness loss can extend to muscle, bone, or supporting structures. Bone, tendon, or muscle may be visible or palpable. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling may also occur.

malignant melanoma tumor stagingTumor size 0-IV Nodal involvement Metastasis T-N-M

In stage 0, the melanoma is confined to one place (in situ) in the epidermis. Melanoma is nearly 100% curable by excision if diagnosed at stage 0. The 5-year survival rate depends on sentinel node biopsy results, which indicate if metastasis has occurred. If metastasis to other organs is found (stage IV), treatment then becomes palliative.

Skin CareEnvironmental Hazards

Irritants and allergens Radiation Sleep- Pruritic skin diseases often interfere with sleep Hygiene mild, moisturizing soaps ; avoid hot water and vigorous scrubbing Nutrition

Nonmelanoma skin cancers

Nonmelanoma skin cancers develop in the epidermis. The most common sites for the development are in sun-exposed areas and include the face, head, neck, back of the hands, and arms.

Stage 2 pressure ulcer

Partial-thickness loss of dermis Shallow open ulcer with red pink wound bed Presents as an intact or ruptured serum-filled blister

Stage 3 pressure ulcer

Presents as a deep crater with possible undermining of adjacent tissue Depth of ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

A pressure dressing is applied to the face and neck of a patient following face-lift surgery. The patient tells the nurse that the dressing feels restrictive and asks if it can be loosened. Which response by the nurse is most appropriate? "This dressing is used to prevent bleeding into the skin." "The dressing will support and secure the incision edges." "A dressing is necessary to prevent infection after surgery." "Face dressings provide time to become adjusted to a change."

Prevention of hematoma formation is the most important postoperative consideration after a face-lift.

Which patient is at highest risk for skin cancer? A 56-year-old Native American with colon polyps. A 72-year-old retired high school chemistry teacher. A 32-year old who uses a tanning booth twice a week. A 44-year-old who regularly bathes with perfumed soap.

Prolonged and repeated sun exposure or use of tanning booths are a major factor in precancerous and cancerous skin lesions.

What factors may increase the risk of problems with the Integumentary system?

Sun damage, UV lights (tanning beds), radiation exposure, age, poor nutrition, corticosteroid use, neuropathy, immobility, incontinence, exposure to allergens, infectious diseases or manifestations (lice etc

The nurse is caring for a patient with anxiety related to a skin condition. Which intervention would be most appropriate at this time for the nurse to add to this patient's plan of care? Encourage the patient to express feelings of anxiety. Use touch to demonstrate acceptance of appearance. Refer the patient for counseling and further evaluation. Teach the patient use of cosmetics and cover-up techniques.

The patient must be allowed time to verbalize feelings of anxiety before other interventions are initiated.

Wet dressings

commonly used when there is oozing from the skin. Oozing usually indicates the presence of an infection and/or inflammation. Salt water or a prescribed solution (i.e., Domeboro powder) is used on the skin by soaking (a foot or hand) or applying compresses to a larger area. Wet dressings are also used to relieve itching, suppress inflammation, and debride a wound. wet dressings increase penetration of topical medications, promote sleep by relieving discomfort, and enhance removal of scales, crusts, and exudate.

Actinic keratosis/solar keratosis

consists of hyperkeratotic papules and plaques occurring on sun-exposed areas premalignant skin lesions that affect nearly all of the older white population. clinical appearance of actinic keratoses are highly varied typical lesion is an irregularly shaped, flat, slightly erythematous papule with indistinct borders and an overlying hard keratotic scale or horn

lesion distribution solitary

a single lession

Photodynamic therapy

a special type of phototherapy that may be used in the treatment of actinic keratosis and malignant skin tumors.

Laser treatment

an efficient surgical tool for many types of dermatologic problems able to produce measurable, repeatable, consistent zones of tissue damage. The CO2 laser is the most common treatment.

Baths

appropriate when large body areas need to be treated. have sedative and antipruritic effects. Some agents, such as oilated oatmeal (Aveeno) and sodium bicarbonate, can be added directly to bath water.

lesion distribution zosterform

bandlike distribution along a dermatone area

lesion distribution synnetric

bilateral distribution

lesion distribution grouped

cluster of lessions

Breslow measurement method of tumor thinkness measurnment

indicates the depth of the tumor in millimeters (Figure 24-5

Keloid

is an overgrowth of collagenous tissue at the sight of skin injury

Vitiligo

is total loss of pigment in the affected area

lesion distribution localized

limited area of involvement that are clearly defined

Nonmelanoma Skin Cancers Basal cell carcinoma

locally invasive malignancy arising from epidermal basal cells Most common type of skin cancer Least deadly Pearly raised borders, depressed center. 90% cure rate, slow growing, 5-FU may be used or surgery

Ultraviolet light (UVL) of different wavelengths

may be used to treat many dermatologic conditions including psoriasis, cutaneous T-cell lymphoma, atopic dermatitis, vitiligo, and pruritis.

lesion distribution CoNFLUENT

merging together

Dermatosis

papulosa nigra are small, pigmented wartlike papules commonly found on the face

Corticosteroids

particularly effective in treating a wide variety of dermatologic conditions can be, intralesionally, or systemically. Topical corticosteroids are used for their local anti-inflammatory action as well as for their antipruritic effects. Intralesional corticosteroids are injected directly into or just beneath the lesion. This method provides a reservoir of medication lasting several weeks to months, commonly used in the treatment of psoriasis, alopecia areata (patchy hair loss), cystic acne, hypertrophic scars, and keloids. Systemic corticosteroids can have remarkable results in the treatment of dermatologic conditions.

Informed consent includes:

risks and benefits, alternatives, must be voluntary, must be explained in terms the patient can understand. make sure surgeon has obtained consent before administering sedation nurse may be witness, should make sure the client understands the consent

lesion distribution DISCRETE

separate from other lessions

Biopsy

the most common diagnostic tests used in the evaluation of a skin lesion. Techniques include punch, incisional, excisional, and shave biopsies. Stains and cultures are used to test for fungal, bacterial, and viral infections. Patch testing and photopatch testing may be used in the evaluation of allergic dermatitis and photoallergic reactions.

Lichenification

thickening of skin as a result of the proliferation of keratinocytes with accentuation of the normal markings of the skin. caused by chronic scratching or rubbing of the skin and is often associated with atopic dermatoses and pruritic conditions. Treatment of the cause of the itching is the key to prevention of lichenification. Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems.

Fluorouracil (5-FU)

topical cytotoxic agent with selective toxicity for sun-damaged cells. available in four strengths (0.5%, 1%, 2%, and 5%) used for the treatment of premalignant (especially actinic keratosis) and some malignant skin diseases. Topical immunomodulators, such as pimecrolimus (Elidel) and tacrolimus (Protopic), are medications used to treat atopic dermatitis. They work by suppressing an overreactive immune system.

lesion distribution ASYMETRIC

unilateral distribution

Antibiotics

used both topically and systemically to treat dermatologic problems often used in combination. apply a thin film lightly to clean skin. If there are manifestations of systemic infection, a systemic antibiotic should be used. Systemic antibiotics are useful in the treatment of bacterial infections and acne vulgaris.

Oral antihistamines

used to treat conditions that exhibit urticaria, angioedema, and pruritus. problems such as atopic dermatitis, allergic dermatitis, and other allergic cutaneous reactions can be mediated with the use of histamine blockers.

The use of radiation for the treatment of basal and squamous cell carcinomas and malignant melanoma

varies greatly according to local practice and availability. a biopsy must first be performed to obtain a pathologic diagnosis. Radiation to malignant cutaneous lesions may be given to reduce tumor size or in palliative treatment.

lesion distribution DIFFUSE

wide distribution