Integumentary

system
Primary lesions
Macule <1cm
Patch >1cm Non-
palpable
Papule <.5 cm

Plaque Coalescence of papule

Nodule .5-2cm
Palpable
Tumor <2cm
solid
Wheal Elevated flat topped
Vesicle <.5 cm
Secondary lesions
Scale Dried exfoliation

Crust Dried exudates

Erosion Loss of epidermis

Ulcer Loss of epidermis with scar

Excoriation Linear erosion

Atrophy Thinning

lichenification thickening
scabies
 Sarcopetes scabiei (itch mite)
 School age; person to person;
institution contaminated article
 1-2months delay
 Pruritis worsen at night
 Erythematous papules & pustules
 Nursing intervention:
 Antihistamine/ topical steroids
 Antiscabies cream; lindane
(Kwell, scabene)
X 2yo: WOF; neurotoxicity
 Thinly;entire body= from neck
down (12-24hrs)
 X wet skin; must be DRY!!
 Close contact must be
treated
 Bedding washed in hot
water/hot dryer
 Mites survive 36hrs in linen
 REMOVE THOROUGHLY
seborrheic
dermatitis
 Recurrent; inflammatory
rxn of skin; family hx of
allergy
 Common: scalp
 “cradle cap”
 Resolve 8-12mos
 Unknown; sebum
production;
overgrowth
malassezia yeast
 Thick, yellowish;
scaly; oil patches;
mild pruritic
 Common: after birth
 after puberty
assessment

 Flaky greasy yellow

scales in the scalp,
forehead, behind ear,
neck, trunk and diaper
area
Nursing care:
 Wash or shampoo affected
area with mild soap
 Mineral oil; massage;
shampoo 10-15 mins, brush
 Apply anti-inflammatory cream
 Anti-dandruff shampoo
 Nursing care:
 Scalp hygiene= shampooing;
mild soap; antiseborrheic
shampoo w/ sulfur & salicylic
acid
 Remove crust (seborrheic
lesions)
 Fine tooth comb/ facial brush
Eczema
(atopic dematitis)
 Pruritic; hereditary
 ONSET= 3 months
 Develop symptoms <5yo
 Irritable
 Difficulty sleeping
 Psychological distress
 Scratching
 Dry skin
 Distribution of lesions:
1. Infantile form= 2-6mos; generalized
2. Childhood= 2-3yo; flexural area
3. Pre-adolescent/ adolescent= 12yo;
flexural area to lesser extent
Therapeutic management:

 Good skin hydration

 Topical corticosteroids
 Antihistamine
 antibiotics
Nursing care:
 X hot water
 X skin and hair products
 Bathe warm 2x/day
 Mild soap
 Pat dry; x rub
 Leave child moist; apply ointment
 X wool or synthetic fiber
 Apply moisture at all times
 Cut finger nails
 X tight clothing and heat
 Use cotton clothe
 Antihistamine
 Diversion of activity,
imagination and play
Nursing care:
 Hydrate px; tepid bath w/
emollient;x dry
 Colloid bath =+ cornstarch
 Antihistamine/ topical
steroids
 Limit allergens & scratching
 X latex products; x
bubble bath;
 x lotion
 Hypoallergenic diet
burns
burns

 Tissue injuries caused by:

 thermal;
 chemical,
 electrical;
 radiation
 or lightning
Burn depth:
 Superficial-thickness burn(1degree)
** pink to red;(-) blisters; painful w/ tingling
sensation; ease by cooling; discomfort for 48
hrs; then healing 3-7days

 Partial thickness burn(2nd Deg)

**larger blister in extensive area; (+) edema;
painful; sensitive to cool air; grafts may be
needed if prolonged healing
Superficial partial: 2-3wks
Deep partial:3-6 wks
 Full-thickness burn(3rd deg)
** leave a deep red, black, brown, white,
yellow area; injured area is dry; disruption
of tissue & expose fats; little or no pain;
scarring & contractures; + remove eschar;
healing: wks to months

 Deep full-thickness burn(4th deg)

**+ muscle & bone; (-)pain, blister &
edema; grafts are required
 Burn location:
 Head, neck or chest = pulmonary
complication

 Face= corneal abrasion

 Ears = auricular chondritis

 Hands & joints= extensive therapy

 Perineal= autocontamination of urine &
feces

 Circumferential burn of extremities=

tourniquet-like effect & lead to vacular
compromise(compartment syndrome)

 Circumferential thorax burn =

inadequate chest wall expansion & pulmo
insufficiency
Systemic damage:
 Respiratory compromise= inhalation
injury to inflammation of throat ^ Upper
airway
 Burn shock= hypovolemic shock
 Growth retardation= suppressed growth
hormone
 Accelerated metabolic rate= energy
expenditures
 Local infection & sepsis= moist, warm
envi for bacteria (staphylococcus &
pseudomonas aeruginosa)
Nursing magt:

 Retain normal fxning;

 Anti pruritic; antibiotics; Vit A, B, C (good
healing)
 Capillary refill, x extremities upon heart
 X contact infected person
 Pain meds; x cold envi.;
 Management of the burn:
I. Emergency phase
**begin at time of injury & ends w/ restoration ;
48-72 hrs ff. the injury
**prevent hypovolemic shock

**+prehospital care & emergency room care

 Remove from source of heat
 Airway; breathing. Circulation
 Cover w/ sterile cloth; x jewelries
 IV; transport
Emergency room care:
 Major burn  Minor burns
 Evaluate degree  Demerol
 Airway; 100% O2; IV;  Analgesics
VS
 Tetanus prophylaxis
 Foley cath = 30-
50ml/hr  Cleansing, debriding,
removing damage
 NGT = x aspiration
agents
 Tetanus prophylaxis;
pain meds  Antimicrobial cream
 escharotomy
II. Resuscitative phase

 Begin in initiation of fluid to near-normal

level of capillary integrity
 Amt. of fluid admin. Is based on the clients
wt & extent of injury
 FLUID REPLACEMENT!
 Prevent shock; maintain vital organ fxn
 Maintain adequate circulating blood volume
‫ ﻹ‬Must be 30-50ml/hr = urine output
‫ ﻹ‬Urinary output= most common & sensitive
noninvasive assessment parameter for cardiac
output & tissue perfusion
‫ ﻹ‬Pulse oximetry; O2 sat
‫ ﻹ‬Elevate head 30 degrees or more if burn is in
face & head
‫ ﻹ‬Isolation; handwashing; antacid
‫ ﻹ‬Meds= x IM & SQ = unreliable if +
hypovolemia
‫ ﻹ‬NPO until (+) bowel sound
‫ﻹ‬ protein, carbo, fats, vits, caloric intake
Escharotomy Fasciotomy

 w/o anesthesia  Incision to SQ tissue

 Lenghtwise incision to & facia
burn eschar to relieve  Operating room w/
constriction & general anesthesia
pressure  Check for pulse.
 24hrs mesh gauze Color.
after procedure Movement.sensation
 Topical antimicrobial  Apply topical
agent antimicrobial
III. Acute phase
 Begin when px is hemodynamically stable,
capillary permeability is restored, & diuresis
begun
 Usually Begins 48-72hrs
 Focus on infection control
 Restorative therapy, this will continue until
wound closure is achieved
 HYDROTHERAPY  DEBRIDMENT
 Wound cleanse by  Removal of eschar to
immersion, spraying prevent bacterial
or showering proliferation
 30 mins or <  Mechanical= painful; +
bleeding; +moist envi
 X in hemodynamicaly
unstable or new skin  Enzymatic= proteolytic
graft &fibronolytic enzyme to
digest necrotic tissue
 Minimize bleeding &
maintain body temp  Surgical= excision of
eschar & coverage of
wound
 Then antimicrobial
agents
IV. Rehabilitative phase
 Final phase
 Overlaps acute care phase & goes well
beyond hospitalization
 Goal are designed to gain independence
 Promote wound healing
 deformities
 strength & fxn
 Emotional support