Integumentary Disorders of the Adult Client

Preprocedure interventions skin biopsy

Verify informed consent has been obtained. Cleanse site as prescribed.

Purulent

Yellow, gray or green drainage due to infection from the wound.

Skin cancer

A malignant lesion of the skin that may or may not metastasizes

MRSA Assessment/interventions

A culture and sensitivity test of the skin or wound confirms the presence of MRSA and leads to choice of appropriate antibiotic therapy. Maintain standard precautions and contact precautions as appropriate to prevent a spread of infection to others. Monitor client closely for signs of further infection, which may result in systemic illness or organ damage. Administer antibiotic therapy as prescribed.

Skin/wound cultuers

A small sterile culture sample is obtained with a sterile applicator and the appropriate type of culture tube (e.g. bacterial or viral). Methods include scraping, punch biopsy and collecting fluids. Viral culture is placed immediately on ice. Sample is sent to laboratory to identify existing organisms.

Candida albicans

A superficial fungal infection of the skin and mucous membranes. Also known as a yeast infection or thrush when in mouth. Risk factors include immunosuppression, such as clients with acquired immunodeficiency syndrome, cancer clients while receiving chemotherapy, clients undergoing long-term antibiotics therapy, clients with diabetes mellitus and obese clients. Common areas of occurrence include the mucous membranes of the mouth, perineum, vagina, axilla and under the breasts.

Types of skin cancer.

Basal cell: basal cell cancer arises from the basal cells contained in the epidermis; mestastasis is rare but underlying tissue destruction can progress to organ tissue. Squamous cell: squamous cell cancer is tumour of the epidermal keratinocytes and can infiltrate surrounding structures and mestasize to lymph nodes. Melanoma: melanoma may occur any place on the body, especially where birthmarks or new moles are apparant, it is highly mestastic to the brain, lung, bones, liver and survival depends on early diagnosis and treatment.

Brown recluse spiders

Bite can cause a skin lesion, a necrotic wound or systemic effects from the toxins (loxoscelism). Applications of ice to decrease enzyme activity of the venom and limit tissue necrosis should be done immediately and intermittently for up to 4 days after the bite. Topical antiseptics and antibiotics may be necessary if the site becomes infected.

Tarantulas

Bites causes swelling, redness, numbness, lymph inflammation and pain at bite site. The tarantula launches its barbed hairs, which penetrate the skin and eyes of the victim, producing a severe inflammatory reaction. Tarantulas hairs are removed as soon as possible, using sticky tape to pull hairs from the skin, and the skin is thoroughly irrigated; saline irrigated; saline irrigations are done for eye exposures. The involved extremity is elevated and immobilized to reduce pain and swelling. Antihistamines are topical or systematic corticosteroids may be prescribed; tetanus prophylaxis is necessary.

Burn location

Burns of the head, neck and chest are associated with pulmonary complications. Burns of the face are associated with corneal abrasions. Burns of the ears are associated with auricular chondritis. Hands and joints require intensive therapy to prevent disability. The perineal area is prone to autocontamination by urine and feces. Circumferential burns of the extremities can produce a tourniquet like effect and lead to vascular compromise (compartment syndrome). Circumferential thorax burns lead to inadequate chest wall expansions and pulmonary insufficiency

Carbon monoxide poisoning

CO is colorless, odorless, tasteless gas that has an affinity for hgb 200 times grater than that of oxygen. Oxygen molecules are displaced and carbon monoxide reversbly binds to hgb to form carboxygemoglobin.

Carbon monoxide blood levels

1-10: normal, 11-20: headache, flushing, decreased visual acuity, decreased cerebral functioning, slight breathlessness, 21-40: headache, nausea, vomitting, drowsiness, tinnitus and vertigo, confusion and stupor, pale to reddish purple skin, decrease bp, increased and irregular heart rate. 41-60: coma, seizures. 61-80:fatal.

Frostbite intervention

Rewarm the affected part rapidly and continuously with a warm water bath or towels at 40 to 42 to thaw frozen part. Handle the affected area gently and immobilized. Avoid using dry heat and rub or massage the part, which may result in further tissue damage. The rewarming process may be painful, analgesics may be necessary. Avoid compression of the injured tissue and apply only loose and nonadherent sterile dressing. Monitor for signs of compartment syndrome. Tetanus prophylaxis is necessary, and topical and system antibiotics may be prescribed. Debridement of necrotic tissue may be necessary; amputation may be necessary if gangrene develops.

Shingles

Same as the herpes zoster infection. An acute viral infection of the nerve structure caused by varicella-zoster, shingles is contagious to individuals who never had chickenpox and have no been vaccinated against the disease.

Scorpion stngs

Scorpions inject venom into the victim through a stinging apparatus on their tail. Most stings cause local pain, inflammation, and mild systemic reactions and are treated with analgesics, wound care and supportive treatment. The bark scorpion can inflict severe and fatal systemic response; the venom is neurotoxic; the victim should be taken to the emergency department immediately (an antivenom is administered for bark scorpion bites).

Normal bacterial flora

Types of normal bacterial flora include gram positive and gram negative staph, pseudomonas sp, and Streptococcus sp. Organisms are shed with normal exfoliation. A pH of 4.2 to 5.6 halts the growth of bacteria.

Herpes zoster (shingles) assessment/interventions

Unilaterally clustered skin vesicles along peripheral sensory nerves on the trunk, thorax or face. Fever, malaise. Burning, pain, Paresthesia. Pruritus. Isolate the client because exudate from the lesions contains the virus (maintain standard and other precautions as appropriate, such as contact precautions). Assess the signs and symptoms of infection, including skin infections and eye infections, skin necrosis can occur. Assess neurovascular status and seventh cranial nerve function, bells palsy is a complication. Use an air mattress/bed cradle on the client's bed if hospitalized and keep the environment cool/warm and touch aggravate the pain. Prevent the client from scratching and rubbing the affected area. Instruct the client to wear lightweight, loose cotton clothing and to avoid wool/synthetic clothing. Teach the client about the prescribed therapies; astringent compress may be prescribed to relieve irritation and pain and to promote crust formation and healing. Teach the client about the measure to keep the skin clean to prevent infection. Teach the client about topical treatment or antiviral medications if prescribed. Zostavax, the vaccination of shingles is recommended for adults 60 years of age and older to reduce the risk of occurrence and associated longterm pain. Antiviral medications may be prescribed.

Pathophysiology of burns

Vasoactive substances are released from the injured tissues and these substances cause an increase in capillary permeability, allowing plasma to seep into the surrounding tissue. The direct injury to the vessels increases capillary permeability. Extensive burns result in generalized edema and decrease in circulation blood. The fluid losses result in a decrease in organ perfusion. The HR increase, CO decrease, blood pressure drops. Initially, hyponatremia and hyperkalemia occur. the hct level increases as a result of plasma loss, this initial increase falls to below normal by 3rd or 4th day after burn as a result of rbc damage and loss at the time of injury. Initially oliguria, then body reabsorbes fluids and diuresis of the exess fluids occurs over the next days to weeks. Blood flow to GI tract decreases leading to intestinal ileus and gi dysfunction. Immune system is depressed. Pulmonary hypertension can develop, decrease in arterial oxygen tension level and decrease lung compliance. no iv therapy could result in hypovolemic shock and death.

Basal cell carcubina

Waxy border, papule, red, central crater. Mestasis is rare.

Stage I pressure ulcer

Skin is intact. Area is red and does not blanch with external pressure. Area may be painful, firm, soft, warm or cooler compared to adjacent tissue.

Stage II pressure ulcer

Skin is not intact. Partial thickness skin loss of the dermis occurs. Presents as a shallow open ulcer with a red pink wound bed as intact or open/ruptured serum filled blister.

Wood's Light examination

Skin is viewed under UV light through special glass to identify superficial infections of the skin. Darken room prior to the examination. Assist the client during adjustment from darkened room. The technique allows clearer inspection of lesions by eliminating the erythema caused by increase blood flow to the area. A glass slide is pressed over the lesion more clearly.

Burn size

Small burns: the response of the body to injury is localized to the injured area. Large or extensive burns: major or extensive burns consist of 25% or more of the total body surface area for an adult or 10% or more of the total body surface for a child. The response of the body to the injury is systemic. The burn affects all major systems of the body.

Snake bites

Some snakes are venomous and can cause a serious systemic reaction in the victim. The victim should be immediately moved to a safe area away from the snake and should rest to decrease venom circulation; the extremity is immobilized and kept below the level of the heart. Constricting clothing and jewelry are removed before swelling occurs. The victim is kept warm and is not allowed to consume caffeinated or alcoholic beverages, which may speed absorption of the venom. If transport to the emergency dept is not immediately done, a constricting band may be applied to proximal to the wound to slow the venom circulation; monitor the circulation frequently and loosen the band if edema occurs. The wound is not incised or sucked to remove the venom; ice is not applied to the wound. Emergency care in the hospital is required as soon as possible, an antivenom may be administered along for supportive care.

Herpes Zoster (shingles)

With a history of chickenpox, shingles is caused by reactivation of the varicella-zoster virus; shingles can occur during nay immunocompromised state in a client with a history of chickenpox. The dormant virus is located in the dorsal nerve root ganglia of the sensory cranial and spinal nerves. Herpes zoster eruptions occur in the segmental distributions on the skin area along the infected nerve and show up after several days of discomfort in the area. Diagnosis is determined by visual examination and by tzanck smear and viral culture that identify the organisms. Postherapeutic neuralgia (severe pain) can remain after the lesions resolve. Herpes zoster is contagious to individuals who never had chickenpox and who have not been vaccinated against the disease. Herpes simplex viruses is another type of virus; type 1 infection caused a cold sore (usually on the lip) and type 2 cause genitla herpes (both types are contagious).

Serosanguineous

Pink colored due to the presence fo a small amount of blood cells mixed with serous drainage. Occurs as normal part of healing process.

Postprocedure interventions skin biopsy

Place specimen in the appropriate container and send to pathology laboratory for analysis. Use surgically aseptic technique for biopsy site dressing. Assess the biopsy site for bleeding and infection. Instruct the client to keep dressing in place for at least 8 hours and then clean daily and use antibiotic ointment as prescribed. Sutures are usually removed in 7 to 10 days. Instruct the client to report signs of excessive drainage or redness or other signs of infection.

Psoriasis interventions/education

Provide emotional support to the client with associated altered body image and decreased self-esteem. Instruct the client not to scratch the affected areas and to keep the skin lubricated as prescribed to minimizing itching. Monitor for and instruct the client to recognize the signs and symptoms of secondary skin problems such as infection, and to report the signs. Instruct client to wear light cotton over affected areas. Assist the client in ways to reduce stress.

Hydrogel

Provides absorption, protection and debridement. Conducive to use with topical agent. Conforms to uneven wound surfaces but allows only partial wound visualization. Requires a secondary dressing for securing. Can promote the growth of pseudomonas and other organisms. Clean base: every 24 hours. Necrotic base: every 6 to 8 hours.

Foam

Provides absorption, protection, insulation and debridement. Conforms to uneven wound surfaces. Requires a secondary dressing for securing. When dressing is saturated or more frequently.

Alginate dressing

Provides hemostasis, debridement, absorption and protection. Can be used as packing for deep wounds and for infected wounds. Requires a secondary dressing for securing. Frequency of dressing changes - when dressing is saturated (every 3 to 5 days) or more frequently.

Adhesive transparent film

Provides protection for partial thickness lesions, debridement, serves as a secondary cover dressing. Provides good would visualization. Is waterproof and reduces pain. Uses is limited to superficial lesions. Is nonabsorbant, adheres to normal and healing tissue. Dressing may be difficult to apply. CLean base: on leakage of exudates. Necrotic base: every 24 hours.

Candida albicans/yeast infection assessment/interventions

Red and irritated appearance that itches and stings. Mucous membranes of the mouth: red and whitish patches. Teach the client to keep skin fold areas clean and dry. For the hospitalized client, inspect skin fold areas frequently, turn and reposition the client frequently, keep the skin and bed linens clean and dry. Provide frequent mouth care as prescribed and avoid irritating products. Provide food and fluids that are tepid in temperature and nonirritating to mucous membranes. Antifungal medication may be prescribed.

Sanguineous

Red drainage from trauma to a blood vessel. May occur with wound cleansing or other trauma to the wound bed. Sanguineous drainage is uncommon.

Carbon monoxide poisoning

Carbon monoxide is a colorless, odorless, and tasteless gas that has an affinity for hemoglobin 200 times greater than that of oxygen. Poisoning occurs from the inhalation of carbon monoxide. Oxygen molecules are displaced and the carbon monoxide reversibly binds to hemoglobin to form carboxyhemoglobin. Tissue hypoxia results.

Burn injuries

Cell destruction on the layers of the skin caused by heat, friction, electricity, radiation or chemicals.

Psychosocial impact

Change in body image decreased general well-being and decreased self-esteem. Social isolation and fear of rejection (because of the embarrassment about changes in skin/appearance). Restrictions in physical activity. Pain. Disruption or loss of employment. Cost of medications, hospitalizations and follow-up care including supplies.

Skin cancer assessment

Change in color, size, shape of preexisting lesions. Pruritus. Local soreness.

Acne Vulgaris

Chronic skin disorder that usually begins in puberty and in more common in males, lesions develop on the face, neck, chest, shoulders and back. Requires active treatment for control until it resolves. Types of lesions includes comodones, pustules, papules and nodules. The exact cause is known but may include androgenic influence on sebaceous glands, increase sebum production and proliferation of propionibacterium acnes (the enzyme reduce lipids to irritating fatty acids). Exacerbations coincides with the menstrual​ cycle in female clients because of hormonal activity, oily skin and genetic predisposition may be contributing. factors.

Psoriasis

Chronic, noninfectious skins inflammation involving keratin synthesis that results in psoriatic patches, however a break in skin integrity can lead to an infection in the affected areas. Various form exist, with psoriasis vulgaris begin the most common. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction and climate changes, a genetic predisposition may also be a cause. This disorder may be exacerbated by the use of certain medications. Koebner phenomenon is the development of psoriatic lesions at the site of injury, such as a scratched or sunburned area. In some individuals with psoriasis, arthritis develops that leads to joint changes similar to those seen in rheumatoid arthritis. The goal of therapy is to reduce cell proliferation and inflammation and the type of therapy prescribed depends on the extent to the disease and the client's response to treatment.

Serous exudate

Clear or straw colored. Occurs as a normal part of the healing process.

Acne vulgaris assessment

Closed comedones are whiteheads and non inflamed lesions that develop as follicles and enlarge with the retention of horny cells. Open comedones are blackheads that result from continuining accumulation of horny cells and sebum, which dilates the follicles. Pustules and papules result as the inflammatory process progresses. Nodules result from total disintegration of a comedone and subsequent collapse of the follicle. Deep scarring can result from nodules.

Cotton gauze

Continuous dry dressing provides absorption and protection. Continuous wet dressing provides protection, a means for delivery of topical treatment, and debridement. WEt to damp dressing provides atraumatic mechanical debridgement. May be painful to removal. Clean base: every 12 to 24 hours. Necrotic base: every 4 to 6 hours.

Frostbite

Damage to tissues and blood vessels as a result of prolonged exposure to cold. Fingers, toes, face, nose and ears often are affected. First degree: involves white plaque surrounded by a ring of hyperemia and edema. Second degree: large, clear fluid filled blisters with partial thickness skin necrosis. Third degree: Involves the formation of small hemorrhagic blisters, usually followed by eschar formation involving the hypodermis requiring debridement. Fourth degree: no blisters or edema noted, full thickness necrosis with visible tissue loss extended into muscle and bone, which may result in gangrene. Amputation may be required.

Poison ivy, poison oak and poison sumac

Dermatitis that develops from contact with urushiol and poision ivy, oak or sumac plants. Papulovesicular lesions and severe pruritus. Cleanse the skin of the plant oils immediately. Apply cool, wet compress to relieve the itching. Apply topical products to relieve the itching and discomfort. Topical or oral glucocorticoids may be prescribed for severe reactions.

Layers of skin

Epidermis, dermis, and hypodermis/subcutaneous fat.

Erysipelas and cellulitis

Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics caused by group A streptococcus, which enters the tissue via an abrasion, bite, trauma or wound. Cellulitis is an infection of the dermis and underlying hypodermis; the causative organism is usually group A strep or staph aureus. Assessment: pain, tenderness, erthema, warmth, edema, fever. Promote rest of the affected area, apply warm compress as prescribed to promote circulation and to decrease comfort, erythema and edema. Apply antibacterial dressings, ointments or gels as prescribed. Administer antibiotics as prescribed for an infection; obtained a culture of the area before initiating the antibiotics.

Deep partial thickness burns

Extends deeper into the skin dermis. Blister formation usually does not occur because the dead tissue layer is thick and sticks to underlying viable dermis. Wound surface is red and dry with white areas in deeper parts. May or may not blanch and edema is moderate. Can convert to full thickness if tissue damage increases with infection, hypoxia or ischemia. Generally, heals in 3 to 6 weeks, but scar formation results and skin grafting may be necessary.

Healing by intention

First intention: wound edges are approximated and held in place (i.e. with sutures) until healing occurs, wound is easily closed and dead space is eliminated. Second intention: this type of healing occurs with injuries and wounds that have tissue loss and require gradual filling in the dead space with connective tissue. Third intention: this type of healing involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigation or removal of debris and exudates; once debris has been removed and inflammation resolves, the wound is closed by first intention.

Hemorrhaging

Frank blood from a leak blood vessel. May require emergency treatment to control bleeding. Hemorrhage is abnormal wound exudate.

Stage IV pressure ulcer

Full thickness loss is present with exposed bone, tendon or muscle. Slough or eschar may be present. Undermining and tunneling may develop.

Stage III pressure ulcer

Full thickness skin loss extends into the dermis and subcutaneous tissues and slough may be present. Subcutaneous tissue may be visible. Undermining and tunnelining may or may not be present.

Pressure ulcer interventions

Identify clients at risk for devleoping a pressure ulcer. Institute measure to prevent pressure ulcers such as appropriate positionng, using pressure relief devices, ensuring adequate nutrition and developing a plan for skin cleansing and care. Perform frequent skin assessments and monitor for alteration in skin integrity. Keep skin dry/sheets wrinkle free, change pads if soiled. Use creams and lotions to lubricate the skin, a barrier proteciton ointment for the inconinent client. Turn and reposition the immobile client every 2 hours or more frequently if necessary, provide active and passive range of motion exercise at least 8 hours. If pressure ulcer present - record the location and size (length, width, dept) and monitor and record the type and wound exudates (do a culture) and assess for undermining and tunnelling. Serosanguinous exudate is expected for the first 2 days, purulent exudates indicates colonization of the wound with bacteria. Use agency protocoles for skin assessment and management of a wound. Treatment may include wound dressing and debridement, skin grafting. Other tretments may include electrical stimulation of wound area (incrases blood vessels growht and stimulates granulation), vacuum assisted wound closure (removes infectious material from the wound and promotes granulation), hyperbaric oxygen therapy, and topical growth factors.

Phases of Wound Healing

Inflammatory: begins at the time of injury and lasts 3-5 days, manifestations include local edema, pain, redness, and warmth. Fibroplastic: begins the fourth day after injury and lasts 2 to 4 weeks; scar tissue forms and granulation tissue forms in the tissue bed. Maturation: begins as early as 3 weeks after the injury and may last for 1 year; scar tissue becomes thinner and is firm and inelastic on palpation.

Deep full thickness burn

Injury extends beyond the skin into underlying fascia and tissues, and muscle, bone and tendons are damaged. Injured areas appears black and sensation is completely absent. Eschar is hard and inelastic. There is lack of pain because nerve endings have been destroyed. Healing takes months and grafts are required.

Deep full thickness burn

Injury extends beyond the skin into underlying fascia and tissues, and muscles, bone and tendons are damaged.

Deep partial thickness burn

Injury extends deep into the dermis

Skin cancer interventions

Instruct clients regarding risk factors/preventative measures. Monthly self skin assessments and to monitor for lesions that do not heal or change characteristics. Advise the client to have moles/lesions removed that are subject to chronic irritation. Instruct the client to wear layered clothing and use sunscreen with appropriate skin protection factor when outdoors. Instruct the client to avoid sun exposure. Management may include surgical or nonsurgical interventions; if medication is prescribed provide instructions about its use. Assist with surgical management which may include cryosurgery, curettage and electodessication, or surgical excision of the lesion.

Acne vulgaris interventions

Instruct the client in presrbied skin cleansing methods, with emphasis on not scrubbing the face and using only topical agents. Instruct the client in administration of topical or oral medications as presrbied. Instruct the client not to squeeze, prick or pick at lesions. Instruct the client to use products labeled non-comedogenic and cosmetics that are water based and to avoid contact with products with an excessive oil base. Instruct the client on the important of follow up.

Full thickness burn

Involves injury and destruction of the epidermis and the dermis; the wound still not healing by reepithelialization and grafting may not be required. Appears dry, hard, leathery, eschar, white or waxy, deep red, yellow, brown or black. Injured surface appears dry. Edema is present under the eschar. A sensation is reduced or absent because of nerve ending the destruction. Healing may take weeks to months and depends on establishing an adequate blood supply. Burn requires removal of schar and split or full thickness skin grafting. Scarring and wound contractures are likely to develop.

Superficial partial thickness burn

Involves injury deeper into the dermis, the blood supply is reduced. Large blisters may cover an extensive area. Edema is presented. Mottled pink to red base and broken epidermis with wet, shiny and weeping surface is characteristics. Burn is painful and sensitive to cold air. Healing in 10 to 21 days but with no scarring, but some minor pigment changes may occur. Grafts may be used if the healing process is prolonged.

Superficial partial thickness burns

Involves injury that extends into the dermis

Superficial thickness burns

Involves injury to the epidermis, the blood supply to the dermis is still intact. Mild to severe erythema (pink to red) is present, but no blisters. Skin blanches with pressure. Burn is painful with tingling, sensation and the pain is eased by cooling. Discomfort lasts about 48 hours, healing occurs in 3 to 6 days. No scarring occurs and skin grafts are not required.

Melanoma

Irregular, circular, bordered lesions with hues of tan, black, or blue. Rapid infiltration into tissues, highly metastatic.

Suspected deep tissue injury

Ischemic subcutaneous tissue injury under intact skin. Appears purple or maroon colored. May be painful, firm or boggy.

Skin Cancer

Malignant lesions of the skin, which may or may not metastasize. Overexposure to the sun is primary cause; other causes and conditions that place the individual at risk include chronic skin damage from repeated injury and irritation, genetic predisposition, ionizing radiation, light skinned race, age older than 60 years, outdoor occupation, and exposure to chemical carcinogens. Diagnosis is confirmed by skin biopsy.

Burns - Age and general health

Mortality rates are higher for children younger than 4 years of age, particularly children from birth to 1 year and for clients older than 65. Debilitating disorders such as cardiac, respiratory, endocrine, and renal disorders, negatively influence the client's response to injury and treatment. Mortality rate is higher when the client has a pre existing disorder at the time of the burn injury.

Squamous cell carcinoma

Oozing, bleeding, crusting lesions. Potentially mestatic. Larger tumors associated with higher risk of metastasis​.

Actinic Keratoses

Actinic keratoses are caused by chronic exposure to the sun and appear as rough, scaly, red or brown lesions that are usually found on the face, scalp, arms and back of hands. Lesions can progress to squamous cell carcinoma. Treatment includes medication, excision, cryotherapy, curettage and laser therapy.

Functions of skin

Acts as the first line defense against infections. Protects underlying tissues and organs from injury. Receives stimuli from the external environment; detects touch, pressure, pain and temperature stimuli; relays information to the nervous system. Maintains normal body temperature. Excretes salts, water, and organic wastes. Protect the body from excessive water loss. Synthesizes vitamin D3, which converts to calcitriol and normal calcium metabolism. Stores nutrients.

Herpes Zoster (Shingles)

An acute viral infection of the nerve structure caused by varicella-zoster. Herpes zoster is contagious to individuals who never had chickenpox and have not been vaccinated against the disease.

Pressure ulcer

Area of tissue damaged that occurs as a result of skin and underlying soft tissue compression from pressure between a surface and bony prominence.

Spider bites

Almost all types of spider bites are venomous and most are not harmful, but bites or stings from brown recluse spiders, black widow spiders and tarantulas (and from scorpions, bees and wasps as well) can product toxic reactions in humans.

Black widow spiders

Bite cause a small red papule. Venom causes neurotoxicity. Ice is applied immediately to inhibit the action of the neurotoxin. Systemic toxicity can occur and the victim may require supportive therapy in the hospital.

Burn

Cell destruction of the layers of the skin caused by heat, friction, electricity, radiation or chemicals.

Skin biopsy

Collection of a small piece of skin tissue for histopathological study. Methods include punch, excisional and shave.

Risk factors for integumentary disorders

Exposure to chemical and environmental pollutants, exposure to radiation, race and age, exposure to the sun or use of indoor tanning, lack of personal hygiene habits, use of harsh soaps or other harsh products, some medications such as long term glucocorticoid use and herbal preparations, nutritional deficiencies, moderate/severe emotional stress, infection with injured areas a the potential entry points for infection, repeated injury and irritation, genetic predisposition, systemic illnesses.

Unstageable pressure ulcer

Full thickness tissue loss in which the wound bed is covered by slough and/or eschar. The true depth and therefore stage of the wound cannot be determined until the slough and/or eschar is removed to visualize the wound bed.

Pressure ulcer

Impairment of skin integrit. Can occur anywhere on the body, tissue damaged results when the skin and underlying tissue are compressed between a bony prominence and an external surface for an extended period of time. The tissue compression restricts blood flow to the skin, which can result in tissue ischemia, inflammation and necrosis, once a pressure ulcer forms it is difficult to heal. Prevention of skin breakdown in any part of the client's body is a major role for the nurse. Risk factors: skin pressure, skin shearing and friction, immobility, malnutrition, incontinence, decreased sensory preception.

Superficial thickness burn

Involved injury to the epidermis

Smoke inhalation injury

Respiratory injury that occurs due to inhalation of products of combustion during a fire

Smoke Inhalation Injury

Respiratory injury that occurs when the victim inhales products of combustion during a fire. The airway is a priority concern in an inhalation injury. Assessment: facial burns, erythema, swelling of oropharynx and nasopharynx, signed nasal hairs, flaring nostrils, stridor, wheezing, and dyspnea, hoarse voice, sooty carbonaceous sputum and cough, tachycardia, agitation and anxiety.

Hydrocolloidal

Provides absorption, protection and debridement. Is waterproof and is painless on removal. Clean base: on leakage of exudates. Necrotic base: every 24 hours.

Biological dressing

Provides protection, and debridement after eschar removal. May be used for dormant and nonhealing wounds that do not respond to other topical therapies. May be used for burns or before pigskin and cadaver skin grafts. Conforms to uneven wound surfaces; reduces pain. Requires a secondary dressing for securing. Topical growth factors: changed daily, skin substitutes: the need for dressing changes varies.

Psoriasis Assessment

Pruritis, shedding: silvery, white scales on raised redened, round plaque that usually affects the scalp, knees, elbows, extensor surface of arms or legs, sacral regions. Yellow discoloration, pitting and thickening of the nails are noted if they are affected. Joint inflammation with psoriatic arthritis.

Methicillin-Resistant Staphyloccocus aureus (MRSA)

Skin or wound becomes infected with MRSA. MRSA is also referred to as a healthcare associated infection. Infection can range from mild to severe and can present as folliculitis or furuncles. Folliculitis is a superficial infection of the followed caused by staphylococcus and presents as a raised red rash and pustules; furuncles are also caused by staph and occur deep in the follicle, present as very painful large raised bumps that may or may not have a pustule. If MRSA infects the blood, sepsis, organ damage and death can occur. MRSA is contagious and is spread to other's by direct contact with infected skin or infected articles, for the client with MRSA, the infection can also be spread to other parts of the body.

Bees and wasps

Stings usually cause a wheal and flare reaction. Emergency care involves quick removal of the stinger and application of an ice pack. The stinger is removed by gently scraping or brushing it off the edge of a needle or similar object, tweezers arenot used because there is a risk of pinching the venom sac. If the victim is allergic to the venom of a bee or wasp, a severe allergic response can occur (hives, pruritis, swelling of the lips and tongue). that can progess to life threatening anaphylaxis, immediate emergency care is required.

Steven Johnson Syndrome

A drug induced skin reaction that occurs through an immunological response. Similar to toxic epidermal necrolysis, another drug-induced skin reaction that results in diffuse erythema and large blisters formation on the skin and mucous membranes. May be mild or severe and may cause vesicles erosions, and crusts on the skin, if severe, systemic reaction occur that involve the respiratory system, renal system and eyes resulting in blindness. Most commonly occurs in clients with cancer who are receiving chemotherapy or immunotherapy. Treatments include immediate discontinuation of the medications causing the syndrome, antibiotics, corticosteroids and supportive therapy may be necessary.

Epidermal appendages

Nails, hair, glands like sebaceous and sweat.

Direct thermal injury

Thermal heat injury can occur to the lower airways by the inhalation of steam or explosive gases or the aspiration of scalding liquids. Injury can occur to the upper airways, which appears erythematous and edematous with mucosal blisters and ulcerations. Mucosal edema can lead to upper airway obstruction, especially during the first 24 to 48 hours. All clients with head or neck burns should be monitored closely for the development of airway obstruction and are considered immediately for endotracheal intubation if obstruction occurs. Erythema of upper aiways. Mucosal blisters and ulcerations.