MS2; Exam3 Integ

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing."

What is Basal Cell Carcinoma?

*Most common type of skin cancer *Least deadly type of skin cancer BCC is a locally invasive malignancy arising from epidermal basal cells, usually occurring in middle-aged & older adults.

Face lift surgery considerations/teaching:

*Most important= prevention of hematoma Ice packs applied for first 24-28 hrs post-op

Post operative management considerations:

1. Assess sites for infection 2. Monitor for adequate circulation 3. Dressings/ice compress

Integument system diagnostics:

1. Cultures: would show positive for organism 2. Biopsy: for accurate diagnosis of cancer or assessment of effectiveness of an intervention 3. WBC: Elevated WBC indicates infection 4. Albumin: Decreased albumin indicates decreased protein resources

Factors Affecting Integumentary System Function:

1. Genetics 2. Age; Increased wrinkling, Loss of elasticity, Graying of hair, Brittle nails with diminished growth 3. Environment (home, work, recreation) 4. Diet 5. Socioeconomic Status 6. Medications (drug therapy - i.e. antibiotics may cause rash, hives)

Preoperative management considerations:

1. Informed consent 2. Realistic expectations 3. Patient understanding of healing time frame

Assessment of skin conditions will always include:

1. location 2. size, 3. general appearance and drainage 4. pain 5. lab data.

Treatment of Cellulitis:

1. warm compresses 2. tissue/blood culture 3. antibiotics

What is cellulitis?

A skin infection of the dermis and underlying hypodermis

Body Image Disturbance Monitoring Interventions:

Ability to care for skin/wound and adapt to body image disturbances

Non-melanoma skin cancers include:

Actinic keratosis Basal cell carcinoma Squamous cell carcinoma

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding?

An irregularly shaped lesion

Collaborative Care for Skin Cancer:

Biopsy Excision Electrocauterization Treatment selection dependent on: *site of tumor *stage *health of the person

A nurse is reviewing the medical record of a client and notes documentation of melasma. What should the nurse anticipate that the client will exhibit?

Blotchy brown macules across the cheeks and forehead

Less invasive cosmetic procedures include:

Botulinum toxin (Botox) Collagen Hyaluronic acid fillers

Mafenide acetate (Sulfamylon) is used in the treatment of:

Burn injuries

A client who previously suffered a burn injury now exhibits a keloid at the burn site. The nurse plans care, knowing that this lesion is caused by hypertrophy of which part of the dermis?

Collagen

What is the function of Subcutaneous Fat (Adipose Tissue)?

Insulates the body. Absorbs shock and protects internal body structures against mechanical injury.

Melanoma has which characteristic?

It is highly metastatic.

Elective Surgical Cosmetic Procedures:

Laser surgery Face lift Liposuction

How are Allergic Dermatologic Problems identified?

Patch testing

What drug classification is Silver sulfadiazine?

antibacterial (topical)

Clients receiving Mafenide acetate (Sulfamylon) should be monitored for:

signs of an acid-base imbalance (hyperventilation) *medication can suppress renal excretion of acid, thereby causing acidosis

Body Image Disturbance Drug Interventions:

Anti-inflammatory medications decrease redness

Risk for Infection Drug Interventions:

Antibiotics as prescribed

A nurse is caring for a client with a burn injury to the lower legs. Nitrofurazone is prescribed to be applied to the sites of injury. Which action should the nurse document in the plan of care as the appropriate method for applying this medication?

Apply a 1/16-inch film directly to the burn sites.

Cryotherapy home care instructions should include:

Apply a warm, damp washcloth if discomfort occurs

What is Malignant Melanoma?

Arises in the melanocytes (cells that produce melanin) Most deadly of skin cancers Can metastasize to any organ

Impaired Skin Integrity Care Interventions:

Assist as needed with ADL's Maintain body temperature Maintain hydration Keep client informed about care Soothe itching

What are the ABCDEs of melanoma?

Asymmetry-one half unlike the other Border irregularity-edges are ragged/notched Color- varied shades of brown/black Diameter- greater than 6mm Evolving-changes in appearance over time

A hospitalized client is diagnosed with scabies. The health care provider (HCP) recommended that the client and the client's roommate be treated with lindane. Which finding if noted on this client's chart would alert the nurse to notify the HCP before the treatment with lindane?

Client history of seizure disorders

Which diagnostic test can give a definitive diagnosis for herpes zoster (shingles)?

Culture of the lesion

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

Elevated hematocrit levels *During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts.

What is the function of Hair?

Extension of epidermis. Mainly cosmetic.

Risk factors for malignant skin neoplasms:

Fair skin Chronic sun exposure Family history of skin cancer Environmental exposures over time

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item to be best to put in the chair under the client?

Foam pad

What is squamous cell carcinoma?

Frequent occurrence on previously damaged skin; invasion of dermis & surrounding skin. *can be highly aggressive and deadly

Massage the medication into the skin from the chin downward. Apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application.

Full-thickness

Which finding indicates a burn client is adequately fluid resuscitated?

HR WDL

Risk for Infection Teaching Interventions:

Hand washing Avoid crowds Take meds as prescribed Adequate nutrition/hydration

Impaired Skin Integrity Monitoring Interventions:

Hemoglobin/Hematocrit/Albumin VS Activity level Diet intake Fluid intake and output Wound location, size, general appearance Environment

What are the most common viral skin infections?

Herpes simplex Herpes zoster Warts

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?

Immobilization of the affected leg for 3-7 days

Liposuction surgery considerations/teaching:

Incision sites taped to reduce bleeding & fluid accumulation May take several months for final results

What is Cellulitis?

Inflammation of connective tissue that often follows break in skin caused by staph or streptococci. Deep inflammation from enzymes produced by bacteria.

Risk for Infection Care Interventions:

Keep skin dry and clean Provide wound care.

The clinic nurse is caring for a client with a diagnosis of scabies who has just been prescribed crotamiton (Eurax). The nurse instructs the client to perform which action when applying this medication?

Massage the medication into the skin from the chin downward. Apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application.

Predisposing factors for bacterial skin infection:

Moisture Obesity Atopic dermatitis Corticosteroid use Antibiotic use Chronic disease (diabetes)

Which assessment finding should the nurse expect to note if scabies is present?

Multiple straight or wavy thread-like lines underneath the skin

A client has been diagnosed with paronychia. The nurse plans care, knowing that this is a disorder that affects what body area?

Nails *fungal infection that most often is caused by Candida albicans

A nurse is reviewing the medical record of a client and notes documentation of reticular skin lesions. What should the nurse expect these lesions to look like?

Net-like in appearance

The nurse is caring for a client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium (Solaraze). The nurse teaches the client that this medication is from which class of medications?

Nonsteroidal anti-inflammatory drugs (NSAIDs)

What is the difference between primary and secondary lesion?

Primary lesions- skin still intact Secondary lesions- oozing or skin breakdown

Impaired Skin Integrity Teaching Interventions:

Protect skin Identify allergens

Body Image Disturbance Care Interventions:

Provide positive reinforcement for self care. Encourage participation in ADL when lesions are dry.

What is the function of Dermis (Coruium)?

Provides flexibility and mechanical strength to the skin. Produces collagen to aid in healing. Rich in nerves that provide sensations of touch, pressure, temperature, pain and itch.

A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite (Dakin solution) to be used in the care of the wound. The nurse should implement which action while using this solution?

Rinse off immediately following irrigation.

What is the function of Glands?

Sebaceous glands produce sebum which lubricates the skin and decreases water loss. Sweat glands assist in regulation of body temperature by evaporative water loss.

A Vigilon nonocclusive burn dressing is prescribed for a client with a partial-thickness burn to the hand. The nurse includes which intervention in the plan of care regarding this treatment?

Secure the Vigilon dressing over the wound with tape.

Which characteristic is associated with Psoriasis?

Silvery-white scaly patches

Bacterial skin infections are usually caused by what organism?

Staphylococcus aureus

Body Image Disturbance Teaching Interventions:

Suggest ways to camouflage or minimize appearance of lesions

What is Actinic keratosis?

Sun damage, common in older whites *most common precancerous skin lesion

Environmental threats to skin:

Sun exposure Medications Irritants and allergens Radiation

Laser surgery considerations/teaching:

Swelling, redness, bruising common after treatment Keep areas moist for first few day Protect skin from sun

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase?

The period from the time the burn was incurred to the time when the client is considered physiologically stable

What is the function of Epidermis?

Thin avascular superficial layer Protective barrier between the body and the environment. Vitamin D synthesis. Melanocytes provide skin color

What topical medication is used to treat eczema?

Topical azelaic acid (Azelex)

Impaired Skin Integrity Drug Interventions:

Topical, steroids, nutritional supplements

What is an adverse effect of 1% silver sulfadiazine?

Transient leukopenia typically occurs after 2 to 3 days of treatment.

Isotretinoin (Amnesteem or Claravis) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Triglyceride level

What is the function of Nails?

Use for scraping and grasping. Protect tips of fingers and toes.

Nutritional threats to skin:

Vitamin deficiencies Protein Fats Dehydration

Risk for Infection Monitoring Interventions:

WBC Signs and symptoms of infection including swelling, redness or ecchymosis

Sunscreens are most effective when applied when?

at least 30 minutes before exposure to the sun

Silver sulfadiazine is used for treatment of:

burns/wounds

What skin layers does Cellulitis affect?

dermal and subcutaneous layers

A client with cellulitis of the lower leg has had cultures collected from the affected area. The nurse reading the culture report understands that which organism is not part of the normal flora of the skin and is a common source of wound infections?

e. coli

Hydrocolloid gel (DuoDERM) should be changed how often?

every 3-5 days

What is a normal adverse reaction to Mafenide acetate (Sulfamylon)?

local discomfort and burning

What is the anticipated therapeutic outcome of an escharotomy?

relief of compartment syndrome

What drug classification is Mafenide acetate (Sulfamylon)?

topical antibacterial/carbonic anhydrase inhibitor

What supplement should be discontinued before isotretinoin therapy?

vitamin A

Nursing Diagnoses for Skin Conditions:

· Body Image Disturbance · Infection · Risk for Injury · Risk for Knowledge Deficit · Impaired Mobility · Impaired Nutrition · Altered Pain · Skin Integrity Impaired · Tissue Integrity Impaired