Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

N1 - Integumentary System Alterations

No description
by

Sarah Fry

on 23 September 2014

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of N1 - Integumentary System Alterations

Assessment
Other Assessment Data
Abscess
Stages
Wound Healing
Nursing Diagnosis
Diagnosis
Implementation
Nursing Management
Alterations in Skin
Integumentary System
Skin Assessment
Areas for documentation
Lesions
Laboratory Data
What interventions for wound care are independent?
Tools used for assessment
Types of Wounds
http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
Dermatitis
Irritant Contact Dermatitis

Irritant causes inflammatory response.
Extent of response determined by time exposed to irritant.
S/Sx
Erythema
blister formation
scaling, drying & crusting
Treatment
avoid source
decrease itching to avoid scratching
corticosteriods
Allergic Contact Dermatitis

S/Sx
wheals
welts
blisters
papules, vesicles
Classified by location of infection
tinea _________
fungal infections feed on keratin
Candidiasis
most common fungal infection
proliferation of normal yeast
thrives in dark moist areas
skin folds, creases, mucous membranes
accumulation of inflammatory cells
produce whitish yellow curdlike substance over area.
Treatment
antifungals - Nystatin
clean dry skin
Fungal Infections
Cellulitis
Bacterial Infection
Staph or Strep
begins with a break in skin
insect bites
Risk factors
anything decreasing sensation or altering skin barrier
Common areas
face, arms, legs
S/Sx
redness, swelling, pain, glossy "stretched" look.
flu-like symptoms
treatment
silver sulfadizine cream
ice packs
R.I.E.
no weight bearing if LEs
Mark area
cavity containing pus and surrounded by inflamed tissue.
Often caused by S. aureus.
Treatment
I&D
antibiotics
Herpes Virus
HSV-1: direct contact transmission
cold sores
Contact precautions if lesions are severe
HSV-2: sexual contact
"genital herpes"
Standard precautions
Herpes Zoster
"Shingles" - reactivation of varicella
Airborne Precautions
S/sx
Pain, itching, burning, red swollen plaques that turn into vesicles filled with milky fluid.
Pain is neuropathic from altered CNS signal processing.
Factors enhancing wound healing
Inflammatory Phase
Proliferative Phase
Maturation Phase
Factors working against healing
Complications
Planning
Goals
Clickers
Ready?!?
Male 14-18 g/dl
Female 12-16 g/dl
Total amt of Hgb in blood
Part of a CBC
Hgb
Albumin
3.5-5 g/dL
Protein formed in liver
Measure of malnutrition
Wound Culture
Coagulation labs
Leukocytes
WBC's
5000-10000/mm3
Part of a CBC
Pain Control
Prevention of Infection
Regain Skin Integrity
Prevent further injury
Keep skin clean and dry
Use moisturizer when and where appropriate.
Nutrition & Hydration
What interventions for wound care are dependent?
Debridement
Mechanical
Enzymatic
Autolytic
SharpMaggot
Topical Therapy types
corticosteriods
soaks/wraps
Moisture retentive dressings
Wound Care Dressing Types
Transparent
Hydrocolloids
Hydrogels
Foams
Aliginates
Collagen
Impregnated
non adherent
Wound Vac
The Client Experiencing
Alterations in Skin
Q&A session
Clickers Ready!
A client is due in hydrotherapy for a burn dressing change. To ensure that the procedure is most tolerable or the client, the nurse takes which of the following actions?
A. Ensures that the client has a robe and slippers.
B. Administers an analgesic 20 minutes before therapy.
C. Sends dressing supplies with the client to hydrotherapy.
D. Administers the intravenous antibiotic 30 min. before therapy.
Full transcript