This action might not be possible to undo. Are you sure you want to continue?
Med/Surg I workbook (aka study guide) for male and female reproductive Question 3 - Review medications given for acne and side effects If I had to take a guess AND THIS IS ONLY MY PERSONAL GUESS, this question will look something like “What is the priority assessment for a patient about to start taking Accutane for acne?” and the answer will involve taking a pregnancy test because Accutane can cause serious damage to a fetus. That is just my guess and I will put all of the information on acne drugs here that I found in the book on pages 459 & 460… 1. 2. 3. 4. Topical benzoyl peroxide (or other antimicrobials) – No side effects listed Topical retinoids – no side effects listed Systemic antibiotics – no side effects listed Isotretinoin (Accutane) – a. Can cause serious damage to fetus b. Should not donate blood while taking or for 1 month following treatment c. Contraindicated for women who are pregnant or who are intending to become pregnant while on the drug d. Linked to liver function test abnormalities e. Liver function, cholesterol, triglycerides, and depression should be monitored.
The first three are intended to suppress new lesions and to minimize scarring. Accutane is used for severe nodulocystic acne tp possible provide lasting remission.
Question 4 - Review skin condition in elderly p439 Table 23-1 on page 439 Changes in skin ● Decreased SQ fat, muscle laxity, degeneration of elastic fibers, collagen stiffening. Related findings in assessment—increased wrinkling, sagging breasts and abdomen, redundant flesh around eyes, slowness of skin to flatten when pinched together (tenting) ● Decreased extracellular water, surface lipids, and sebaceous gland activity. Related findings in assessment—dry, flaking skin with possible sings of excoriation caused by scratching ● Decreased activity of apocrine and sebaceous glands. Assessment findings—dry skin with minimal to no perspiration, skin color uneven ● Increased capillary fragility and permeability. Assessment findings—evidence of bruising ● Increased focal melanocytes in basal layer with pigment accumulation. Assessment findings—solar lentigines on face and back of hands
loss of hair in outer half or outer third of eyebrow and back of legs ● Cumulative androgen effect. turgor = a pinch on the back of the hand tenting = dehydration Nursing Diagnosis for the elderly = risk for injury related to skin tearing Vesicles are more clear-fluid filled. increased skin fragility. a personal history of sun exposure. The book states “the most reliable areas in which to assess erythema. ● ● ● ● ● ● ● . and general state of health Skin changes directly related to aging include: decreased turgor. and peripheral vibration ● Decreased proliferative capacity. and jaundice are the areas of least pigmentation. conjunctivae. pallor. such as the sclerae. Finding—thick. Finding—gray or white hair ● Decreased oil. coarse hair. scaly scalp ● Decreased density of hair. nutrition. wrinkling. Assessment findings—diminished rate of wound healing ● Decreased immunocompetence. look at the palms and nailbeds (skin is lighter there) to assess color changes. Finding—facial hirsutism (ex.How do you assess various lesions Before I get into the book stuff. Finding—dry. and buccal mucosa.Diminished blood supply. while pustules are more like pimples. vascular lesions. brittle nails with diminished growth ● Increased keratin. cyanosis. lips. Older women with hairy chins). touch. thinning. Assessment finding—increase in neoplasms Changes in hair ● Decreased melanin and melanocytes. and benign neoplasms ● Question 5 . Finding—longitudinal ridging ● Decreased circulation. skin is cool to touch. diminished awareness of pain. Finding—prolonged return of blood to nails on blanching Rate of age-related skin changes influenced by: hereditary. nail beds. baldness Changes in nails ● Decreased peripheral blood supply. like chicken pox.” There is a box on page 442 that reinforces this as well. herpes zoster (shingles) follows a nerve route through dermatomes so it will look streaky. Assessment findings—decrease in rosy appearance of skin and mucous membranes. here are the things she said in class that sounded like test clues regarding skin lesions: ● For dark-skinned patients. nystatin and myconazole are for treating yeast infections. dryness. decreasing estrogen levels. hygiene practices. Wheals are like mosquito bites and are treated with benadryl. Finding—thinning and loss of hair. temperature.
Bacterial Infections Occur when balance b/w the host and microorganisms is altered ● Can occur as primary infection following break in skin or can occur as secondary infection to already damaged skin (Staphylococcus aureus) Predisposing factors: moisture. and warts Treatment (Table 24-5 (pg. firm. most seem to need antibiotics and warm moist compresses Viral Infections ● Virus infects cell. There was alot of information. 456)) ● Herpes: symptomatic medications.. salicylic acid Fungal Infections ● Skin.Understand skin infections and how to treat them. evolving/elevated. assessing skin is a lot like assessing other areas of the body. diameter. atopic dermatitis. which stands for asymmetry. skin lesion may develop ● Lesions can occur as result from inflammatory response to viral infections Most common ● Herpes simplex. Tried to put the most important. color. size. I will ask her specifically what we need to know for this question and get back to everyone. hair and nails may become infected (candidiasis and tinea unguium) ● Appearance of microscopic hyphae (threadlike structures) indicates fungal infection Treatment (table 24-6 (pg 457)) ● Antifungal creams. record its color.Besides that. distribution. oral antifungal Candidiasis ● Keep skin area clean and dry . Don’t forget about the pneumonic ABCDEFG. location. herpes zoster. drainage is infectious ● Good skin hygiene and infection control practices needed to keep from spreading Treatment ● Table 24-4 (pg 454). compare symmetrically ● general exam first. cryosurgery. antiviral agents ● Verruca: removal (surgery. If you find a lesion. etc) ● Plantar Warts: topical immunotherapy. borders. then focus on lesions ● use the metric system and appropriate terminology. and then keep the following in mind during the objective portion of the exam: ● private room w/ good lighting ● patient comfortable ● systematic approach. liwuid nitrogen. Getting a complete medical history and list of medications is listed. systemic corticosteroids and antibiotics. growing. chronic disease (diabetes) ● Good hygiene and health inhibit.. Question 6 . duct tape. and shape. obesity.
Rectal and throat cultures may also be taken. excisional. For bacteria. or abscesses. type of anesthesia to .Understand patient teaching related to skin biopsy Skin Biposy is found in Chapter 23. or cervical discharge are cultured to assess presence of gonorrhea or Chlamydia. ● Percutaneously drawn samples need skin preparation with adequate skin contact and drying time using alcohol or tincture of iodine or alcoholic chlorhexidine (10. (See table 23-9.How do you obtain cultures for various infections? Blood: (pg 240) ● Collect blood culture samples before beginning antibiotic therapy. 1302) ● Specimens of vaginal. biopsy for information) For the four different types of biopsy (punch. Have them sign the consent form. p. 916) ● Tests for the presence of bacteria including Clostridium difficile. material obtained from intact pustules. prevent infection). a phlebotomy team should draw the samples. Cervical. make sure that the patient understands the purpose of their test. urethral. For viruses. depending on data obtained from sexual history. bullae. Skin: (pg. ● Z-technique: rotating a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion.5%) rather than povidone-iodine. but urethra contains bacteria and a few WBCs. Urine: (pg. explain about the necessity of proper site prep/cleaning (ie. Vaginal. bacterial. Stool: (pg. (2) Ztechnique. ● Levine’s technique: rotating a culture swab over a cleansed 1-cm2 area near the center of the wound using sufficient pressure to extract wound fluid from deep tissue layers. 446) ● Test identifies fungal. vesicle/bulla and exudate taken from base of lesion. and shave). and viral organisms. scraping or swab of skin performed. 445-446. Wound: (pg. 199) ● Concurrent swab specimens are obtained from wounds using (1) wound exudates. incisional. 1114) ● Confirms suspected urinary tract infection and identifies causative organisms. ● Wound exudate: samples visible wound exudates from the wound bed before cleansing. Normall. bladder is sterile. and (3) Levine’s technique.● Powder on nonmucosal surfaces to prevent recurrence Question 7 . ● Where available. and Urethral: (pg. Question 8 . For fungi.
Review the table on lesions and characteristics Page 441. elevated moles.5cm in diameter. second-degree burn Plaque -circumscribed. Explain to them that how much they bleed during and post procedure will vary with the type of biopsy that they have. lipoma.5cm in diameter -Examples: -psoriasis. Question 9 . measies. it is a patch -Examples: -freckles. petechiae. basal cell carcinoma Vesicle -circumscribed. herpes zoster (shingles). urticarial Pustule -elevated. impetigo . solid lesion -<0.5cm in diameter -if lesion is >0. incisional-wedge shaped incisions make into the lesion.what their particular biopsy entails (punch-takes a full thickness sking biopsy. and shavethe use of a single edged razor blade to shave off superficial lesions). Finally. >0. dependent upon the type of biopsy).be used with the biopsy. superficial lesion filled with purulent fluid -Examples: -acne. superficial collection of serous fluid -<0. café au lait spot. vitiligo (complete depigmentation) Papule -elevated. excisional-skin will be closed with subcutaneous and skin sutures. table 23-4 Primary lesions Macule -circumsicribed. edematous. irregularly shaped area -diameter variable -Examples: -insect bite. typically used for very large specimens. Explain the use of bandaging following the procedure (varies from a bandaid to pressure dressing. elevated. it is a nodule -Examples: -wart (verruca).5cm in diameter -Examples: -varicella (chickenpox).5cm in diameter -if lesion. seborrheic and actinic keratosis Wheal -firm. the nurse will give the patient their specific postprocedure instructions. flat mole (nevus). flat area with a change in skin color -<0. superficial solid lesion ->0.5cm.
striae Excoriation -area in which the epidermis is missing.Page 442. Treatment of the cause of the itching is the key to prevent of lichenification. healed wound Ulcer -loss of the epidermis and extending into dermis -crater-like -irregular shape -Examples -pressure ulcer. Although any area of the body may be affected. shins. . and nape of the neck are common sites. Lichenification is caused by chronic scratching or rubbing of the skin and is often associated with atopic dermatoses and pruritic conditions. Excorations may be evident in the lichenfied skin as a result of persistent pruritus and scratching. dead epidermal cells produced by abnormal keratinization & shedding -Examples: -flaking of skin after a drug reaction or sunburn Scar -abnormal formation of connective tissue that replaces normal skin -Examples: -surgical incision. cracks at corner of mouth Scale -excess. scratch Question 10 . chancre Atrophy -depression in skin resulting from thinning of the epidermis or dermis -Examples -aged skin. the forearms. exposing the dermis -Examples: -abrasion.Look up lichenification and understand Lichenification is a thickening of skin as a result of the proliferation of keratocytes with accentuation of the normal markings of the skin. the hands. table 23-5 Secondary lesions Fissure -linear crack or break from the epidermis to dermis -dry to moist -Examples -athlete’s foot.
singed nasal hair. hoarseness. Inhalation injury above the glottis ● Upper airway injury-inhalation of hot air. Alkalis (oven and drain cleaners. oxalic and hydrofluoric acid).cause of majority of deaths at fire scene ● CO displaces O2 on Hemoglobin molecule causing carboxyhemoglobinemia. creosote) ● Tissue destruction can last up to 72 hours ● Alkali burns are much most difficult to treat than acid burns due to not being neutralized by tissue fluids ● Alkalis cause protein synthesis and liquefaction ● Remove clothing as soon as possible Smoke and Inhalation Injury ● Inhalation of hot air or noxious chemicals cause damage to tissues in respiratory tract. blistering. scald. alkalis.presence of facial burns. carbonaceous sputum. Inhalation injury below glottis ● Lower airway injury. act as protective mechanism ● Redness and swelling occur when damage is present ● Smoke inhalation injuries are major predictor of mortality in burn patients 1. hypoxia ● Death occurs at CO levels greater than 20% ● Skin is Cherry Red ● Treat with 100% O2 1.pulmonary edema (may not appear until 12-24 hours after burn) then show as acute respiratory distress syndrome (ARDS)-can drown Electrical Burns . Carbon monoxide poisoning. history of being burning in an enclosed space and clothing burns around chest and neck 1. and organic compounds. can cause airway collapse ● Gases may be cooled to body temp before reach lung tissue ● Respiratory mucosa may have damage but seldom happens due to vocal cords and glottis.usually due to chemicals ● Tissue damage related to duration of exposure to smoke or chemical ● Clinical manifestations.Know your burns the degrees Thermal Burns ● Caused by flame. heavy industrial cleaners). flash. hydrochloric. or contact with hot objects ● Most common type of burn Chemical Burns ● Tissue injury or destruction from acids. darkened oral and nasal membranes. fertilizers. steam or smoke ● Mucosal burns of oropharynx and larynx. gasoline. edema ● Mechanical obstruction may occur ● Clues that there is upper airway injury.redness.Question 11 .chemicals (household cleaners. painful swallowing. phenols (chemical disinfectants.
fluid filled vesicles (red. May . may not continue to be the case Shock – fluid third spacing can lead to drop in bp. scald. SCDs or graduated compression stockings used Electrolyte imbalance – from fluid shifts (emergent phase) then diuresis in acute phase. severe metabolic acidosis and myoglobinuria Can cause immediate cardiac standstill or ventricular fibrillation. blanching on pressure. possible involvement of muscles. even it is open at one point.● ● ● ● ● ● Intense heat generated from an electric current Direct damage to nerves and vessels. sending pt into hypovolemic shock (bp <90 systolic) – emergent phase Edema – fluid shifts (emergent phase) DVT – immobility can lead to clots either Lovenox. waxy white. or hard skin. tissue resistance. no vesicles or blisters ● May be caused from superficial burn or quick heat flash 2nd degree (Deep) ● Epidermis and dermis involved to varying depths ● Epithelial regeneration still intact. wet). pain and mild swelling. so not sure exactly what she’s going for but these are the highlights from lecture and the book … Airway – (this was emphasized repeatedly) airway may become occluded following burn. and length of time current flow was sustained Most damage is below the skin Patient is at risk for dysrhythmias or cardiac arrest. leathery.dry. visible thrombosed vessels. tar. shiny. tactile and pain sensation intact ● Clinical appearance. causeing tissue anoxia and death Severity depends on voltage. insensitivity to pain.delayed arrest may happen without warning during first 24 hours after injury 1st degree (Superficial) ● Superficial epidermal damage. contact burns. electric current 3rd and 4th degree ● All skin elements and local nerve endings destroyed ● Coagulation necrosis present ● Surgical intervention required for healing ● Clinical appearance.erythema. chemical. mild to moderate edema ● May be caused by flame. tendons. surface area in contact with current. flash. severe pain due to nerve injury.Understand what can happen to burn patient after the burn This one is pretty vague. and bones Question 12 . current pathways. remain viable ● Clinical appearance.
exercise and splinting used to prevent. if it's not given. Communication with family. Question 14 . caregivers. guilt. without it risk of infection increases significantly (acute phase) Contractures and scarring – (rehab phase) positioning. 1721 Table 67-4) . anger. as well as grafts in extreme burns Emotional changes – fear.lead to LOC changes.4mL lactated Ringer's solution per kilogram (kg) of body weight per percent of total body surface area (%TBSA) burned = total fluid requirements for 1st 24 hours after burn 4 mL x weight in kg x % TBSA = total fluid requirements for 1st 24 hours Application 1/2 of total in first 8 hrs 1/4 of total second 8 hrs 1/4 of total third 8 hrs Example: 70 kg patient with 50% TBSA burn 4 mL x 70 kg x 50% TBSA = 14. cardiac issues (K+ imbalances) Infection – skin is first line of defense.000 mL in 24 hours 1st 8 hrs = 7000 mL 2nd 8 hrs = 3500 mL 3rd 8 hrs = 3500 mL For more examples see the discussions from the burn week (I think week 7). 483 Table 25-12 Formula . and burn team is essential. depression may be experienced by burn patient. anxiety. Question 13 .How do you monitor that a patient is receiving enough fluid There was not a whole lot of information provided in the book or on the ppt slides for this.Be able to calculate per the Parkland formula Parkland Formula p. but this is the information I could find related to this… • Most accurate thing to do to monitor for efficient fluids is to watch for signs of hypovolemic shock (clinical manifestations found on p. just make sure you actually figure the % TBSA.
dry mucous membranes o Decreased skin turgor. If it is just a burn localized to the leg. stroke volume. Early and aggressive nutritional support can mean the difference between life and death. Enteral feedings are necessary for patients who can not physically eat. For burn victims. Patients with large burns.o Decreased preload. optimize wound healing and minimize the negative effects of catabolism and hypermetabolism. this would not be necessary. and agitation o Absent bowel sounds o Decreased hemoglobin and hematocrit levels. Checking bowel sounds is very important. increased specific gravity of urine. increased pulse. cool and clammy intact skin o Decreased cerebral perfusion – causes anxiety. drowsiness. lethargy. 309 Table 17-4.Understand nutrition and burns p 486 Once fluid replacement has been addressed. confusion. concentrated urine o Increased respirations o Weakness. Failure to supply adequate calories and protein leads to malnutrition and delayed healing. more than 20% TBSA can develop a paralytic ileus within the first few hours of tube feeding because of the body's systemic response to major trauma. nutrition takes priority in the initial emergent phase. the signs for dehydration are found on p. and changes in electrolytes o Decreased blood pressure. Many burn victims will also suffer respiratory dysfunctions due to the inhalation of hot air which can damage the lung tissue. at least every 8 hours.Care planning for burn patient An extensive table showing collaborative care is on page 482 but it contains a lot of information. coma Question 15 . Some of them overlap with the signs of hypovolemic shock. Question 16 . I’m not sure if the signs for a patient with just dehydration are equivalent to signs found in burn patients though. . decreased capillary refill o Postural hypotension. dizziness o Weight loss – daily weights o Seizure. o Restlessness. decreased cerebrovascular perfusion o Decreased urine output. increased pulse • I’m guessing that another way to ensure they are receiving enough fluid is to monitor for signs of dehydration. Most of them will need to be intubated if the burn is severe. their survival depends on rapid and thorough assessment. confusion o Thirst. But just in case. and capillary refill o Increased respirations – decreased respirations present in late hypovolemic shock o Decreased urine output o Pallor. for example.
the wound can begin to be cleaned. use the Parkland (Baxter) formula. hands. eyes arms. Once the patient is in a stable condition. Coverage is the primary goal for burn wounds. Colloidal solutions such as albumin are normally given. An IV access will obviously need to be started and cared for throughout the clients stay. Ears especially. To determine the TBSA. it’s important to remember that infection is the most serious threat to further tissue injury and possible sepsis. Try and keep the patients hands and arms elevated up on a pillow to reduce fluid loss and to minimize edema. necrotic skin is removed as well as any foreign materials that may have lodged within the skin during the accident. This is a sterile process and the dressings will need to be changed anywhere from ever 12-24 hours to once every 14 days. Question 17 . Signs and symptoms of infection need to be monitored for and reported immediately to the caregiver. at least two large-bored IV access routes must be obtained. When caring for a patient with severe burns. I’m assuming that the patient would be pumped full of pain medication before this process was done. There is rarely enough unburned skin in the major burn patient for immediate skin grafting. should be kept free of pressure because they already have poor vascularization. Silver sulfadizine cream is put on gauze that is then applied to the burn. need more attention and care if they are burned.People suffering from burns will also have significant fluid loss that should be monitored. They will need to be receiving large quantities of fluids and possibly blood and that is the reason for the two access points.Care plan and positioning for patients with burns . This is sometimes done on a cart shower (picture on page 484). Urine output should be closely monitored and routine lab tests should be run to monitor fluid and electrolyte balance. Some parts of the body. and ears. Sometimes the patient’s burn wound will be left open and covered with antimicrobial cream but it can also be covered with dressing. Remember to use your PPEs when cleaning a patients wound. Gauze can be tucked behind the ears. If the patient has burns greater than 15% TBSA. ABGs are drawn to determine adequacy of ventilation and perfusion in all patients with suspected or confirmed inhalation injury. such as the face. It seems that the most popular form is using moist dressings. During debridement.
Question #16 is about the care plan for a burn patient so I’m not going to do it again. If I forgot anything. charred appearance ● Strong burn odor ● Impaired sensation when touched absence of pain with severe pain in surrounding tissues . please add!! Question 18 . dark brown. These are all I could find. P 477 – 479 Thermal Burns Partial thickness superficial ● Redness ● Pain ● Moderate to severe tenderness ● Minimal edema ● Blanching with pressure Partial thickness deep ● Moist blebs. I’ll just emailed her for clarification. These are assessment findings for the following. There are a few different positions listed in the book to use with burn patients depending on what you are trying to accomplish/treat. Circumstantial Burns Not too sure what she is talking about here. Patient with ear burns cannot use pillows due to pressure they place on the ears so the head can be elevated using a rolled towel placed under the shoulders. Burned limbs should be elevated above the level of the heart to decrease edema. patient should be placed in a high fowler’s position (unless contraindicated). I will just do the various positions listed for burn patients. so if it changes I’ll update the information. When treating possible smoke inhalation without intubating the patient. blisters ● Mottled white. pink to cherry-red ● Hypersensitive to touch or air ● Moderate to severe pain ● Blanching with pressure Full-thickness (3rd and 4th degree_) ● Dry. This can be done by placing hands and arms on pillows or placing feet and legs in splints. Patient with neck burns also cannot use a pillow so they can sleep with their head hanging slightly over the top of the mattress to encourage hyperextension.Assessment of circumstantial burns. leathery eschar ● Waxy white.
The book says that sometimes burns can act as a tourniquet.● Lack of blanching with pressure Electrical Burns ● Leathery. white. or charred skin ● Burn odor ● Loss of consciousness ● Impaired touch sensation ● Minimal or absent pain ● Dysrhythmias ● Cardiac arrest ● Location of contact points ● Diminished peripheral circulation in injured extremity ● Thermal burns if clothing ignites ● Fractures or dislocations from force of current ● Head or neck injury if fall occurred ● Depth and extent of wound difficult to visualize. swelling of injured tissue ● Degeneration of exposed tissue ● Discoloration of injured skin ● Localized pain ● Edema of surrounding tissue ● Tissue destruction may continue up to 72 hours ● Respiratory distress if chemical inhaled ● Decreased muscle coordination ● Paralysis So I just got back a message from her..the nurse plans to". about an hour ago · Thus...... She said it should have said circumference burn instead of circumstantial. You need to give probably fluids to correct it.the question "The patient does not have a pulse.."administer IV fluids" .. assume injury greater than what is seen Chemical Burns ● Burning ● Redness. She basically gave us an answer to the exam.