Medical Surgical Nursing

Medical-Surgical Nursing Function of skin - protection, prevents penetration, perception, temperature regulation, identification, communication, wound repair, absorption and excretion, production of vitamin D Epidermis - The outer layer of skin that acts as a watertight protective covering. Dead Skin. Dermis - Middle layer of skin that is composed of elastic fibers. Functions to provide strength, mechanical support and to protect muscle, bone, and organs. Nerve receptors produce feelings of heat, cold, pain, touch and pressure have ceruminous glands produce sebum Hypodermis (subcutaneous layer) - Innermost layer of the skin. Composed of adipose tissue; functions as a site for storage, shock absorber, insulates deep tissue, and anchors skin to underlying tissues. Age related skin changes - -Delayed Healing: skin repairs proceed more slowly -Epidermal and dermal thinning: slow repairs, decreased vvitamin D production, reduced number of langerhans cells (sagging and wrinkling due to fiber loss) -Increased risk of infection and sun damage -Decreased vitamin D synthesis -Decreased melanocyte activiey: pale skin and reduced tolerance for sun exposure -Diminished blood supple: slow healing, and reduced ability to lose heat -Decreased glandular acitivity: sweat glands tend to overheat - Decreased skin turgor, wrinkling, fragility, dryness, roughness, vascular lesions. Assessment: Objective Data - Color, pigmentation, bruising, vascularity, lesions, discolorations, unusually odor, temperature, turgor, mobility, moisture, and texture. Assessment: Subjective Data - Itching, burning, dry, irritated, pins and needles, pain scale, longevity, etiology. Topical Medications - Lotions, creams, pastes, shampoos, and ointments that are applied to the surface of the skin and affect only that area; a medication delivery route. Slows the overactive epidermis without affecting other tissues and cause sloughing of the rapidly growing epidermal cells. Topical Corticosteroids - Used for inflammatory effects; often limited to twice a day for a four week period. Used to treat dermatitis and psoriasis. Systemic Steroids - Not generally used for skin conditions because it could possibly provoke a flare-up. Possibly used for hives. Can be used when topical measures are not effective. Phototherapy - A therapy that involves repeated exposure to UV lights, which slows the rapid cell growth of skin cells. Cellulitis - Inflammation of subcutaneous, loose connective tissue; causes swelling; possible skin infections. Symptoms: Hot to touch, tender, erythematous, edematous areas with diffused borders, chills, malaise, and fever. Eczema - noninfectious, inflammatory skin disease characterized by redness, blisters, scabs, and itching. Long term inflammation of the skin; hypersensitivity of the skin with hyperactivity inflammation and hyperactivity Psoriasis - A common skin disorder characterized by flare-ups in which red papules covered with silvery scales occur on the elbows, knees, scalp, back, or buttocks. Can be as little as a cosmetic annoyance, and can severe enough to be physically disabling. Sun Exposure - Major factor in precancerous and cancerous lesions such as: Actinic keratoses, Basal cell carcinoma, Squamous cell carcinoma, and Malignant melanoma. Patient Teaching: Sunscreen with a minimum of 15 SPF, wearing hats, teaching on danger of burns on overcast days and the dangers of tanning beds. Avoid the sun between 11am and 3pm. Skin Cancer Prevention: ABCDE rule. - A-Asymmetry B-Border Irregularity C-Color Change/Variation D-Diameter more than 6mm E-Evolving appearance Actinic Keratosis - a precancerous skin growth that occurs on sun-damaged skin. Malignant Melanoma - Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised. Risk Factors: Chronic UV exposure, tanning beds, fair skin and eyes, severe and frequent burns, genetic factors, multiple and atypical moles. Macule - flat skin lesion with a change in color. ex: freckles, petechiae, measles Papule - small, solid, raised lesion on surface of the skin. Ex: Wart, elevated mole. Vesicle - Circumscribed, superficial collection of serous fluid ex: varicella, herpes, shingles (zoster), second degree burn. Plaque - a solid mass greater than 1 cm in diameter and limited to the surface of the skin. ex: psoriasis, seborrheic and actinic keratoses. Pustule - elevated, pus-filled (purulent fluid) lesion on the skin. ex: acne, Impetigo Risk Factors for Skin tears in the elderly - dry skin due to dehydration areas of ecchymoses presence of friction, shearing, or pressure form impaired sensory perception impaired mobility multiple medications Categories of Skin Tears - Category One- Without tissue loss. Category Two- Partial tissue loss. Category Three- Complete tissue loss in which the epidermal flap is missing. Biopsy - The removal of living tissue from the body for diagnostic examination. Shave Biopsy - A technique using a surgical blade to "shave" tissue from the epidermis and upper dermis. Punch Biopsy - Removal of a small core of tissue using a hollow punch. Excisional Biopsy - Removal of an entire lesion. Keloid - Thick scar resulting from excessive growth of fibrous tissue. How to differentiate between a macule and papule - Shine a flashlight at a right angle to the lesion: a papule will cast a shadow, macule will not. Pallor (skin color) - Dark Skinned People- Ashy Gray tone Brown Skinned People- Yellow-Brown Color Senile Purpura - A common, benign condition characterised by recurrent formation of purple ecchymoses (bruises) on the extensor surfaces of forearms following minor trauma. Stasis Dermatitis - Generally occurs on the legs as a result of venous stasis and edema and is seen in conjunction with varicosities, phlebitis, and vascular trauma. Erythema and pruritis occurs first, after which scaling, development of petechiae, and hyperpigmentation occurs. lesions may become ulcerated, particularly around the ankles and tibia. Acne vulgaris - Typically begins with puberty, continues through the teens, and then begins to subside. occasionally it persists, or it can recur several years later. This typically occurs because of the increase in sex hormones in teens, this stimulates production of the sebaceous glands, causing increase production of sebum. A well balanced diet is recommended for this. Acne rosacea - Usually begins between ages 30-50 years. Characterized by erythema, papules, pustules, and telangiectases. It occurs on the face over the cheeks and bridge of the nose. Tx: Avoiding triggers, as well as topical antibiotics. Furuncle - Boils, Inflammation of hair follicles. The organism responsible is usually staphylococcus aureus. Any skin area with hair can be affected. Initially there is a deep, firm, red, painful nodule 1-5 cm in diameter. The nodules changes to a large and tender cystic nodule accompanied by cellulitis. The lesion may drain large amounts of pus and necrotic tissue. Carbuncles - A collection of infected hair follicles and most commonly occur on the back of the neck, the upper back, and the lateral thighs. it begins as a firm mass and evolves into an erythematous, painful, swollen mass. It may drain through many openings in the mass. Abscesses may develop with fever, chills, and malaise. Herpes simplex - Type 1: non-genital, Type 2: Most often associated with genital herpes. The virus is embedded in a nerve ganglion that innervates the site of the lesion. The virus travels along a nerve path. Reactivation is brought about by exposure to ultraviolet light, skin irritation, fever, fatigue, or stress. S/S: HSV-1 appears as lesions on the lips, and nares that are commonly called cold sores or fever blisters. No drug will completely cure it. Dx: H&P. Tx: antiviralsHastens healing but does not completely cure it. Herpes zoster - Causes chickenpox and shingles. Follow the nerve path as well. S/S: Chills and low grade fevers and possibly some GI disturbances. There may be aching or discomfort along the nerve pathway, with or without erythema. about 3-5 days after onset, small groups of vesicles appear on the skin. They usually found on the trunk and spread halfway around the body, following the nerve pathways leading from the spinal nerve to the skin. Usually only affect one side of the body or face. Pain can persist after they are completely healed. Dx: H&P. No cure. Tx: is usually symptomtic and trying to relieve pain. Onychomycosis - Fungal infections of the fingernails and toenails Tinea pedis - Athletes foot, Usually between the toes. May spread to the entire foot. Can cause blistering, peeling, cracking, and itching. Can spread to other parts of the body if unchecked. The causative agents usually are Trichophyton Mentagrophytes and Trichophyton rubrum. Dx: H&P. Tx: Keeping the area clean and dry, and exposed to air and sunlight. Burrows solution soaks can help. topical antifungals are used. Pediculosis - Three types, Capitis, corporis, and pubis. A parasitic infection. This is caused by lice. S/S: itching. Dx: Inspection. Tx: Permethrin, pyrethrins, and malathion. Monitor liver function. Benzyl alcohol lotion 5% suffocates the lice. Suspected deep tissue injury - Intact skin with purple or maroon discoloration. tissue may be firm, boggy, painful, cool, or warm. Stage I pressure ulcer - An area of intact skin that is reddened, deep pink, or mottled that does not blanch Stage II pressure ulcer - Partial thickness skin loss involving the epidermis and or dermis, the skin can appear blistered or abraded, or as a shallow crater. The area around the damaged skin will appear red and can feel warm to the touch. Stage III pressure ulcer - The skin is ulcerated. There is a crater like ulcer, and the underlying subcutaneous tissue is involved in the destructive process. The ulcer may or may not be infected. bacterial infection is almost always present. Stage IV pressure ulcer - There is deep ulceration and necrosis involving deeper underlying muscle and possibly bone tissue. The ulcer can be dry, black, and covered with a tough accumulation of necrotic tissue, or it can be made up of wet and oozing dead cells and purulent exudates. Depth can be determined. Unstageable - Full thickness wounds with eschar and/ or tissue that obscures depth determination. Eschar - Dead matter that is sloughed off from the surface of the skin, especially after a burn Solar Lentigo - Liver Spots/Age Spots. Flat tan, brown, or black spots on the skin common with age. Age spots are harmless and don't need treatment. In some cases, prescription creams and procedures can remove them or make them less noticeable Pallor - Pale. skin Erythema - Redness of the skin due to capillary dilation Cyanosis - a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood. Jaundice - yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood Uriticaria - Hives; reddish, whitish, plaques edematous; usually show up on torso; usually caused by drugs, histamine, bed linen detergent Ecchymosis - Bruising or discoloration associated with bleeding within or under the skin. Petechiae - Non-blanchable, pinpoint purple or red spots from minute hemorrhages under the skin. Lesion - a pathologic change of the tissues due to disease or injury Nevi - small, dark skin growths that develop from melanocytes in the skin; also known as moles Wheal - Elevated irregular shaped area of cutaneous edema, solid, transient, variable diameter (insect bites, urticarial, allergic reaction, lupus erythematosus) Vitilgo - A condition caused by the destruction of melanin that results in the appearance of white patches on the skin Impetigo - bacterial inflammatory skin disease characterized by vesicles, pustules, and crusted-over lesions Excoriation - Skin sore or abrasion produced by scratching or scraping. ex. Scabies First Degree Burn - Superficial burns through only the epidermis. Skin is red, dry, painful, no blisters. Ex: Sunburn Second Degree Burn - A partial-thickness burn involving the epidermis and the dermis. Blisters present. Very Painful. Third & Fourth Degree Burn - A full-thickness burns that involve the epidermis, dermis, and varying levels of the subcutaneous and underlying structures. May involve muscles, tendons, and bones. Little or no pain. Nerve endings are destroyed. Hirsutism - Excess body hair in females, hair on face, arms, breasts, and abdomen. Generally caused by an excess of hormones related to polycstic ovarian syndrome. Diaphoresis - Excessive sweating. could be result of hyperthermia, extreme anxiety, pain or shock. also hyperthyroidism. Contact Dermatitis - An inflammation of the skin caused by having contact with certain chemicals or substances; many of these substances are used in cosmetology. ex: Poison Ivy Seborrheic Dermatitis - Cradle Cap; an inflammation that causes scaling and itching of the upper layers of the skin or scalp Tinea Corporis - ringworm infection of the nonhairy parts of the skin characterized by elevated lesions with red margins Braden Scale - Assessment used to determine one's risk for developing a pressure ulcer. Score of 16 or less indicates risk for pressure ulcer. Categories assessed: Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear Edema - Swelling; Abnormal accumulation of fluid in interstitial spaces of tissues. Pitting Edema - edema that retains an imprint when touched Non-Pitting Edema - Skin shiny and taut; feels puffy and tight Bony prominence - Areas of the body that are at the greatest risk for developing pressure sores resulting in wounds. Elbow, heels, hips, ankles, shoulders, back, and the back of the head. Hair Assessment - color, texture, distribution, lesions, thickeness, shiney?, location. alpecia - baldness Nail assessment - shape and contour, consistency, color, capillary refill, clubbing Capillary Refill - A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure. clubbing of nails - deformity of fingers and fingernails associated with underlying medical conditions or diseases that cause the finger tissue to increase and nails to curve downward. Chronic Hypoxia caused by heart disease, cystic fibrosis, chronic inflammatory bowel disease.