Med Surg Exam 1 Review: Patient Care for Hearing & Skin Disorders - NRBS 3510, Complete 100% updated guide -SUNY Downstate Medical Center.

Med Surg Exam 1 Review: Patient Care for Hearing & Skin Disorders - NRBS 3510, Complete 100% updated guide -SUNY Downstate Medical Center. Med Surg Exam 1 Nursing Care of Patient with Hearing/Balance Disorders (Ch 59) 1. Assessment of hearing and balance & testing a. Inspect the external ear b. Otoscopic examination i. Auricle is gently pulled upward and backward. In children downward and backward ii. Instrument: Otoscope c. Gross auditory acuity i. Whisper test→ each ear is tested starting w/ better ear. Other ear is occluded. Series of 3 letters and numbers is whispered and pt is asked to repeat them d. Weber test used for bone conduction loss (hearing loss) i. Tuning fork struck and placed on pt’s head ii. Normal→ hears equal (center of head) iii. Conductive→ better in affected ear iv. Sensorineural→ better in better ear e. Rinne test→ distinguish b/w conductive or sensorineural. Compares air conduction to bone conduction i. Tuning fork struck and brought to ear then end is placed on mastoid ii. Conductive→ mastoid process ≥ sounds at ear canal (sound is hear as long or longer in affected ear→ hearing loss) iii. Sensorineural→ sound at canal ≥ mastoid process (air conduction is audible longer than bone conduction in affected ear) Condition Hearing Loss Pathophysiology - Affects more than 28M ppl in the U.S - ↑ incidence with age (Presbycusis) Types: - Conductive → caused by external middle ear problem (otitis media, otosclerosis, presence of foreign body) - Sensorineural→ caused by damage to cochlea or vestibulocochlear nerveMed Surg Exam 1 - Mixed→ both conductive and sensorineural - Functional (psychogenic) → caused by emotional problem Clinical Manifestations - Tinnitus→ perception of sound, “ringing in ears” - ↑ Inability to hear in a group - turning up volume on TV - Impairment is gradual, often not recognized - As hearing loss ↑, person may experience deterioration of speech, fatigue, indifference social isolation, withdrawal Treatment - Aural rehabilitation→ auditory training, speech reading/ training - Hearing aids→ sounds to signal - implanted hearing devices (bone conduction devices, cochlear implants) Nursing intervention - speak slowly & distinctly - reduce background noise & distractions - face the person and get their attention - speak into less impaired ear - use gestures and facial expressions - if needed write out info or obtain sign language translatorMed Surg Exam 1 External Ear Conditions Cerumen Impaction Foreign Bodies External Otitis Malignant External Otitis Image Pathophysiology - earwax blockage - object in ear - AKA Swimmer’s Ear - Inflammation, irritation, or infection of external ear canal commonly caused by Staphylococcus or Pseudomonas, or fungal infection from Aspergillus - Rare, progressive infection that affects external auditory canal, surrounding tissue, & skull - bacteria spread from floor of ear canal to tissues and into bones at base of skull→ may damage/ destroy bone Clinical Manifestations - Hearing loss - feeling of fullness in ear - itching - otalgia - tinnitus - pain/ crying - infection - hearing loss - pain/ tenderness - discharge - edema - erythema (redness) - pruritus - hearing loss - fullness feeling in ear - yellow or green drainage from ear that has smell - ear pain - hearing loss - itching - fever - trouble swallowing Risk Factors* - ear picking→ ear infection - abnormalities of external auditory canal - foreign body impaction - excessive earwax - fear/ stress - aging - curious child - small objects - ears swabs - warm, humid places - harsh cleaning of ear - trauma - dry ear canal skin - foreign body - excess cerumen - external otitis - chemotherapy - diabetes - weakened immune system Diagnostic Tests - otoscope to view inner ear - ear inspection with otoscope - Medical history/ physical exam - otoscope - inspection of ear - neurological exam to assess cranial nerves affected - lab test of drainageMed Surg Exam 1 - CT/ MRI→ signs of bone infection Treatment - Irrigation, suction, or instrumentation - gentle irrigation should be used with lowest pressure, directing stream behind obstruction - Glycerin, mineral oil. ½ strength H2O2, or peroxide in glyceryl to soften cerumen - Irrigation, suction, or instrumentation - Objects that swell (veggies/ insects) shouldn’t be irrigated - may require extraction in operating room - Therapy→ reduce discomfort, edema and treat infection - Wick may be inserted in canal to keep it open and facilitate med administration - antibiotic ear drop/ corticosteroid, antimicrob, antifungal - pain med - Antibiotics for long period- combo of antipseudomonal agents and aminoglycoside - Aggressive local wound care - dead/ infected tissue may need to be removed Nursing Intervention - Manually remove, irrigate or use agents - Promote ear hygiene - Inspect previously occluded tympanic membrane - patient education - teach child not to put objects in ears - keep small object out of reach - patient education - patient education -Monitor kidney functions, auditory function, and serum aminoglycoside levels. (can be ototoxic & nephrotoxic) Infection & Prevention* - buildup can lead to ear infection→ worsening s/s Prevention: - removal of impacted earwax - Infection can occur if object was in ear for long time - S/S: pain, bleeding, deafness, fluid discharge, redness/ swelling, temperature Prevention: - removal of object asap - water trapped in ear canal may cause growth of bacteria or fungi Prevention: - ear plugs, swimming cap in water - avoid water/ soap/ shampoo from getting in ear - never use cotton tips Prevention: - Dry ear after it gets wet - avoid polluted water - protect ear canal - maintain good glucose control if you have diabetes Health Promotion* - safe and effective ear hygiene - safe and effective ear hygiene - keep ear dry - safe and effective ear hygiene - safe and effective ear hygieneMed Surg Exam 1 Middle Ear Conditions Tympanic Membrane Perforation Serous otitis media/ Acute Otitis Media Chronic Otitis Media Image Pathophysiology - AKA ruptured eardrum - tear in tympanic membrane leading to connection b/w external auditory canal & middle ear - Most common in children - SOM→ fluid in middle ear w/o evidence of infection - AOM→ infection of middle ear ● Streptococcus pneumonia, Haemophilus influenzae, Moraxella catarrhalis - Long-standing perforation of ear eardrum or presence of cholesteatoma - result from recurrent acute otitis media - damages tympanic membrane, ossicle, and involves mastoid Clinical Manifestations - ear pain - mucus like pus-filled or bloody drainage - hearing loss - tinnitus - vertigo - N/V - SOM→ otalgia, tugging/ pulling ear, crying, loss of balance, fever, fluid drainage, LOA, ear fullness - AOM→ otalgia, fever, hearing loss - ear pain - fever - fussiness - pus-like drainage - hearing loss Risk Factors* - infection (otitis media) - trauma (loud noises) - rapid changes in pressure→ otalgia, otorrhea, tinnitus, vertigo - foreign objects - Age (children) - Group child care - Infant feeding - Poor air quality - common cold - SOM→ adenoids - Trauma - ear infection - incomplete healing of eardrum after ear tube was dislodged/ take out Diagnostic Tests - otoscope - culture test of drainage - tuning fork evaluation - Tympanometry - Otoscopy - pneumatic otoscopy - Pt history - Presenting s/s - otoscope - culture test of fluid - CT scan→ spread of infection - Hearing testMed Surg Exam 1 - hearing test - Tympanometry Treatment - can heal on it’s own - eardrum patch - surgery→ Tympanoplasty - SOM→ myringotomy, fluid removal via ear tube, adenoidectomy (removal of adenoids), corticosteroids - AOM→ Antibiotic therapy, Myringotomy (create hole in eardrum to allow fluid to drain out) or tympanotomy - Prevent by treating acute otitis - topical antibiotics - Tympanoplasty→ reconstruction of tympanic membrane - Ossiculoplasty→ reconstruction of bones of middle ear. Prostheses used to reconnect ossicles to reestablish sound conduction - Mastoidectomy→ removal of diseased bone, mastoid air cells & cholesteatoma Nursing Intervention - Pt education ● Keep ear dry ● Refrain from cleaning ear ● Avoid blowing nose - Positioning→ child situp, raise head on pillow, lie on unaffected ear - Heat application - Diet→ breastfeed - proper hygiene - monitor hearing loss - proper hygiene - monitor hearing loss Infection & Prevention* - treat otitis media - prevent water from getting in ear AOM→ avoid smoking & exposure to secondhand smoke - treatment of acute otitis media will prevent infection Health Promotion* - protect eardrums during flight - keep ear free of objects - guard against loud noises - Prevent common colds/ other illnesses - smoke free environment - breast-feed - bottle feed in upright position - promptly treat acute otitis media - Prevent AOM 2. Auditory testing ● Weber test used for bone conduction loss (hearing loss) a. Tuning fork struck and placed on pt’s head b. Normal→ hears equal (center of head) c. Conductive→ better in affected ear d. Sensorineural→ better in better ear ● Rinne test→ distinguish b/w conductive or sensorineural. Compares air conduction to bone conduction e. Tuning fork struck and brought to ear then end is placed on mastoid f. Conductive→ mastoid process ≥ sounds at ear canal (sound is hear as long or longer in affected ear→ hearing loss)Med Surg Exam 1 g. Sensorineural→ sound at canal ≥ mastoid process (air conduction is audible longer than bone conduction in affected ear) 3. Mastoid surgical care a. Anxiety→ reduction of anxiety i. Reinforce info & pt education ii. Provide support and allow to discuss anxieties b. Acute pain→ relieving pain i. Medicate w/ analgesics for ear discomfort ii. Occasional sharp pain may occur→ eustachian tube opens and allows air into middle ear iii. Throbbing pain and fever may indicate infection c. Risk for infection→ preventing infection i. Monitor for s/s of infection ii. Administer antibiotics as ordered iii. Prevent contamination of ear w/ water d. Risk for trauma related to imbalance or vertigo→ preventing injury i. Safety measure such as assisting w/ ambulation ii. Antiemetics or antivertigo meds iii. Activity restrictions e. Disturbed auditory sensory perception→ improving communication & hearing i. Hearing may be reduced after surgery b/c of edema, blood accumulation, fluid in ear ii. Use measures to improve hearing & communication 4. Vestibular problems (Inner ear) ● Vestibular system is the balance system falls result from dysfunctions→100,000 hip fractures a year. ● Cranial Nerve VIII is affected ● Dizziness: any altered sense of orientation in space ● Vertigo: the illusion of motion or a spinning sensation ● Nystagmus: involuntary rhythmic movement of the eyes associated with vestibular dysfunction ● Motion sickness: treated with meclizine or dimenhydrinate before the trigger. Caused by vestibular overstimulation.Med Surg Exam 1 Inner Ear Conditions Meniere's Disease Tinnitus Labyrinthitis Benign positional vertigo (BPV) Acoustic Neuroma Image Pathophysiology -abnormality in inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct - “Ringing in ears” Inflammation of labyrinth -Bacterial or viral (MMR and flu) -Complications of otitis media Occurs when position of the pt head is changed with respect to gravity while laying down. -due to disruptions of calcium carbonate crystals within semicircular canal. - AKA vestibular schwannomas - Tumor of the VIII cranial nerve leading from inner ear to brain - develop from Schwann cells covering vestibular nerve Clinical Manifestations Vestibular: -fluctuating, progressive hearing loss, tinnitus, feeling pressure, episodic incapacitating vertigo (n/v sometimes) Cochlear: above but no vertigo. - Roaring, buzzing, hissing - clicking - humming -Both hearing and balance is affected -n/v, hearing loss, possibly tinnitus. Usually w n/v - hearing loss - tinnitus - LOB - Dizziness Risk Factors* Common in adults averaging 40. - age related hearing loss - ear injury/ Infections, smoking, stress stimulated by head trauma, infection, etc - Age 30-60 - Parents with rare genetic disorderMed Surg Exam 1 infection - loud noises - tobacco/ alcohol use neurofibromatosis Diagnostic Tests -Assess the vertigo episodes, diaphoresis and feeling unbalanced. -Physical exams are usually normal. -Weber test lateralized to ear opposite of hearing loss (sensorineural). - Symptoms - Medical history - audiometry Based on symptoms -ENG (records eye movement) -Blood tests History & based on symptoms - symptoms - audiometry - imaging→ detect tumor Treatment -Low-sodium diet to minimize fluid retention (2000 mg/day) -Meclizine (Antivert) to shorten attacks. -tranquilizers (diazepam) to help vertigo. -Antiemetics (promethazine) for n/v. -Diuretic to ⇣ pressure -Surgery: endolymphatic sac decompression or vestibular nerve sectioning. - earwax removal - treating BV condition - hearing aids - changing medication - noise suppression - counseling→ tinnitus retraining therapy, CBT -IV antibiotics therapy, fluid replacement, antihistamines (meclizine), and antiemetic -Viral is treated based on symptoms Bed rest and repositioning techniques. -Meclizine -Prochlorperazine -Vestibular rehabpromotes active use of vestibular system: stress management, biofeedback, vocational rehab, PT. - monitor the tumor for growth - regular imaging & hearing test - surgery - radiation therapy Nursing Intervention Guide pt on treatment plan and dietary restrictions. - Pt education - use hearing protection - turn down volume Limit alcohol, caffeine, nicotine Guide pt on medication adherence and educate on disorder and prevention Encourage/educate patient to adhere to medications - Provide positioning techniques and vestibular rehab - protect ear from loud noises - assess if pt needs hearing aid Ototoxicity: ● From medications that damage the cochlea (hearing), vestibular (balance), or cranial nerve VIII ● IV medications especially aminoglycosides because they destroy hair cells in the organ Corti.Med Surg Exam 1 ● Antineoplastic agents also cause hair cell death in cochlea → hearing loss ● Blood levels of medications should be monitored → audiogram twice a week during therapy Bone conduction devices: ● Used if hearing aid is contraindicated ● Implanted in skull postauricularly under skin ● External device worn above ear (magnetic) to collect sound and transmit to implant ● Semi and total implantable devices available Just examples Cochlear implants: ● For bilateral hearing when aids don't help ● Directly stimulates auditory nerve ● External hearing aid in conjunctionMed Surg Exam 1 Nursing Care of Patient with Skin Disorders (Ch 56) 1. Assessment of Skin ● Physical examination- assessing appearance of skin ○ Perfusion ○ Abnormalities, growths, rashes, scabs, moles, etc. ○ Vital signs, assess for signs & symptoms of infection ● Focused dermatologic health history ● Assess risk factors to derm conditions 2. Skin Cancer Cancer Basal Cell Carcinoma Squamous Melanoma Image Pathophysiology Invasion and erosion of contiguous (adjoining) tissues. (Least aggressive of the skin cancers) Malignant proliferation arising from the epidermis. Its precursor is typically actinic keratosis. Change in new growth on the skin, arising from cutaneous epidermal melanocytes. Clinical Manifestations -Small waxy nodule that is shiny, flat, gray, or yellow -Rarely metastasizes -Recurrence common - Less aggressive than melanoma but can cause death -Rough thickened, scaly tumor -May be asymptomatic or bleed -Border is wide, more infiltrated, more inflammatory -Typically dark, red or blue colored, or a mix of any of these, and irregular in shape - Itching, rapid growth, ulceration, or bleeding -Superficial spreading or nodular Diagnostic tests Observation by physician Observation by physician -Biopsy tells level type, level, and thickness of lesion. -Palpation of lymph nodes around area. A: Asymmetry B: Irregular borders C: Change in color D: Diameter greater than 6mm E: Evolving -Staging of Cancer: TNM T: size of tumor N: regional lymph nodesMed Surg Exam 1 M: distant metastasis Treatment -Mohs micrographic surgery: excision layer by layer. -Electrosurgery: small lesions. -Cryosurgery: freezing it. -Radiation therapy, photodynamic therapy, or topical chemotherapy creams -Mohs micrographic surgery: excision layer by layer. -Electrosurgery: small lesions. -Cryosurgery: freezing it. -Radiation therapy, photodynamic therapy, or topical chemotherapy creams -Surgical excision or wide local excision -Skin grafting if necessary -Lymph node dissection if necessary/ radiation therapy -Stage 3 and 4 can be managed w IV checkpoint inhibitors -Chemotherapy Nursing Diagnosis/ Nursing Intervention Interventions: -Educate patient on prevention of skin cancer and self-care after treatment -Follow up every 3 months for a year Interventions: -Educate patient on prevention of skin cancer and self-care after treatment -Follow up every 3 months for a year -Acute pain -Anxiety -Depression -Deficient knowledge Interventions: -Inspect skin carefully -Ask questions about new pigmented lesions/ changes in skin -Assess knowledge level and risk factors -Assess coping and anxiety -After surgery, provide comfort and administer analgesics -Promote transitional care 3. Infectious diseases Infectious Disease Impetigo Folliculitis/furuncles/ carbuncles Herpes Zoster/Simplex Hidradenitis Suppurativa Image Furuncle: Shingles:Med Surg Exam 1 Carbuncle: Herpes simplex: Pathophysiology -superficial infection of the skin caused by staphylococci, streptococci, or multiple bacteria. -Contagious/spread to other parts of body. -Folliculitis: inflammatory condition of the cells within the wall and ostia of the hair follicles that may be caused by a bacterial, viral, fungal, or parasitic infection. MRSA could develop -Furuncle: acute inflammation arising deep in one or more hair follicles and spreading into the surrounding dermis. -Carbuncle: an abscess of the skin and subcutaneous tissue. Herpes Zoster (shingles): caused by varicella-zoster virus (VZV). Painful vesicular eruptions along the areas of distribution of dermatomes. -Herpes Simplex: herpes simplex type 1 occurs on the skin of the lips, mouth, gums, or tongue (or on the skin around the mouth) and type 2 occurs in the genital area, but both viral types can be found in both locations. Primary disorder of follicular occlusion, often resulting in infection, that causes eventual hypertrophic formation of scar tissue in the area of the sweat glands Clinical Manifestations -Most commonly seen on face or extremities. -Small red macules→ thin-walled vesicles that rupture→honey yellow crust Furuncles: start as red, small, raised, painful pimple and a “head” of the boil develops. Carbuncle: Purulent material can be absorbed ad result in fever, pain, leukocytosis, and sepsis. Herpes Zoster: pre eruptive phase: dormant VZV becomes reactivated. Acute eruptive phase: unilateral patchy erythematous, vesicles form, rupture, and crust. Unrelenting and severe pain. Postherpetic neuralgia: pain localized to the dermatomal area. -Firm, pea-sized nodule that causes discomfort. -ruptures and discharges pus, causing more nodules -Form scars when they rupture. Diagnostic tests -Bacterial cultures Observation Blood tests observationMed Surg Exam 1 and physical exam Culture & sensitivity test Treatment -Crusts are removed by warm soap solution. -Topical antibacterial therapy applied to lesions -Systemic antibiotic agents may be prescribed to treat infections that are widespread -Should never be squeezed. -Systemic antibiotic therapy from culture and sensitivity -Oral dicloxacillin and cephalosporins -Small incision with a scalpel to relieve pressure. -Oral antiviral agents such as acyclovir, valacyclovir, or famciclovir for 7-10 days. -Pain is controlled with analgesic agents -systemic corticosteroids or gabapentin. -Warm compress and wear loose-fitting clothes -Oral antibiotic agents like erythromycin, tetracycline, minocycline, doxycycline. -NSAIDs -Silver-impregnated alginate dressings -Incision and drainage with gauze packs -Surgery using skin grafts as last resort. -CO2 laser surgery Nursing Diagnosis/ Nursing intervention -Educate pt to bathe at least once daily with bactericidal soap. - Encourage good hygiene to stop spread -IV fluids, fever reduction, etc for pt that are ill. -Warm, moist compress on boil to help heal. -Antibacterial soap/ointment may be applied. -Eliminate staphylococcal pathogen from environment - clean everything and keep good hygiene -Educate patients on the importance of taking antivirals as prescribed. -Vesicles and rashes can be soothed by applying calamine lotion or 5% aluminum acetate. -Relaxation techniques -VZV vaccine to reduce primary infection. -Education about management Fungal Infections Tinea (ringworm) Pediculosis capitis, corporis, pubis Scabies ImageMed Surg Exam 1 Pathophysiology Caused by Microsporum and Trichphyton -Lice infestation; live on outside of the body and depend on host for nourishment -Scabies: infestation of the skin by the itch mite Sarcoptes scabiei. From substandard hygienic conditions and those who are sexually active. Clinical Manifestations Affect head, body, groin, feet, and nails The bite of the insect causes intense pruritus, and the resultant scratching often leads to secondary bacterial infection, such as impetigo or furunculosis -severe itching and immunologic reaction to mite. Diagnostic tests Obtain specimen by using a scalpel or glass slide to remove scales from the margin of the lesion. KOH is added Examination, Wood’s light Observation Sample of mites byproducts Treatment Antifungals - shampoo containing pyrethrin compounds with piperonyl butoxide or rinsing with permethrin -fine-toothed comb dipped in vinegar to remove any remaining nits or nit shells -bathe with soap and water Nursing Diagnosis/ Nursing intervention Educate on: -medications, use of oral and topical agents, and shampoos. -hygiene and reduce the spread (dont share anything) -Keep skin folds dry to prevent overgrowth -wear clean underwear and socks -Avoid excessive heat and humidity -Hair loss is associated with tinea capitis is temporary -Not sign of uncleanliness -Family members should be treating as well -Wear gloves when providing careMed Surg Exam 1 4. Inflammatory & autoimmune disorders Disorder Pruritus Psoriasis Image Pathophysiology -Most common symptom of derm disorders -Scratching the pruritic area causes the inflamed cells and nerve endings to release histamine, which produces more pruritus. -Worse at night. -May be the first indication of a systemic internal disease such as diabetes, blood disorders, or cancer -Can be caused by medications, soaps, chemicals, radiation therapy, heat, stress -Chronic inflammatory and autoimmune disorder (remission and exacerbation) -Genetic predisposition -Emotional stress and anxiety aggravate the condition, and trauma, infections, and seasonal and hormonal changes may also serve as triggers -Epidermis becomes infiltrated by activated T cells and cytokines, resulting in both vascular engorgement and proliferation of keratinocytes. Epidermal hyperplasia results. Clinical Manifestations Itchiness and rash (most of the time) -Plaquelike lesions that have a silvery, scaly, and flaky appearance -If the scales are scraped away, the dark red base of the lesion is exposed, producing multiple bleeding points. -Nails and scalp can become thick and flakey Complications: infection and rheumatoid factor-negative arthritis Diagnostic tests History and physical exam History and physical exam, biopsy Treatment Topical antipruritic agents, capsaicin cream Topical corticosteroids, Oral antihistamines -Management of stress Baths to remove scales with oils, colloidal oatmeal preparations, or coal tar preparations and apply medications and emollient creams -Topical corticosteroids as an anti-inflammatory with occlusive dressing -Tazarotene (Vitamin A) and calcipotriene (Vitamin D) can suppress development of plaques. -Phototherapy -Biologics and immunomodulators for systemic treatmenttargets the T cells, slowing the cytokines and immuneMed Surg Exam 1 deviation Nursing Diagnosis/ Nursing intervention -Reinforce regimen and educate pt on specific points of care -Rate the extent of itching -Bathe with cooler water, dry skin folds, don't rub with towel -Educate pt to avoid situations that cause vasodilation -Cotton clothing to sleep -Room kept cool and humidified -Trim nails Diagnoses: Deficient knowledge, Impaired skin integrity, disturbed body image -Pt should consult with a rheumatologist to assist in the diagnosis and long-term treatment of this disorder. Interventions: -increase understanding of disease and treatment regimen -help develop coping strategies and self-acceptance -Achieve smoother skin with control of lesions -Avoid hot water Disorder Stevens-Johnson Syndrome Image Pathophysiology ● May be caused from medications ● widespread erythema and macule formation with blistering, resulting in epidermal detachment or sloughi erosion formation. ● Genetic mutations Clinical Manifestations ● Conjunctival burning or itching, cutaneous tenderness, fever, cough, sore throat, headache, myalgias ● Rapid onset of erythema of skin surface and mucous membranes ● Large, flaccid bullae develop in some areas ● Sheets of epidermis is shed Diagnostic tests ● Collections of cellular material from freshly denuded area ● Acknowledge medication history ● CBC may show leukopenia and normochromic normocytic anemia. ● Skin biopsy showing necrotic keratinocytes with epithelial detachment Treatment ● IV crystalloid fluids to maintain fluid and electrolyte balanceMed Surg Exam 1 ● Systemic corticosteroids (controversial) ● IVIG ● Immunosuppressive agents (cyclosporine or cyclophosphamide) Nursing Diagnosis/ Nursing intervention ● Impaired tissue integrity related to epidermal shedding ● Deficient fluid volume and electrolyte losses related to loss of fluids from impaired skin ● Risk for impaired body temperature related to heat loss secondary to skin loss ● Acute pain related to denuded skin, oral lesion, and possible infection ● Anxiety related to the physical appearance of the skin and prognosis Interventions: ● Maintaining skin and mucous membrane integrity ● Attaining fluid balance ● Preventing hypothermia (due to loss of skin) ● Relieving pain ● Reducing anxiety ● Monitoring and managing potential complications (sepsis, conjunctival retraction, scars, and corneal lesions) ● Promoting home, community-based, and transitional care Blistering Diseases: →From bacterial, fungal, viral infections →Allergic contact reactions →Burns →Metabolic disorders IgG autoimmune reactions ● Pemphigus vulgaris→ blistering of skin and mucosa ● Pemphigus foliaceus → blistering of skin ● Paraneoplastic pemphigus → Blistering of GI or Resp tract associated with neoplasm → Assessment: ● For signs of infection ● Pain, pruritus, discomfort ● Impact of disease on ADLs →Diagnosis: made through examination and biopsy ● Acute Pain: skin and oral cavity ● Impaired skin integrity ● Disturbed body image ● Deficient fluid volume due to loss of tissue fluids → Interventions: ● Pay attention to oral hygiene: Chlorhexidine rinse and spit (avoid commercial mouthwashes) ● Keep lips moist ● Cool mist humidifier ● Cool baths and dressings ● Monitor for hypothermiaMed Surg Exam 1 Kaposi Sarcoma →Malignancy of endothelial cells that line the small blood vessels →Manifested by lesions of skin, oral cavity, GI tract, and lugs →Dark, reddish-purple lesions →Older men Mediterranean or Jewish chronic or African men 5. Skin care ● Protecting the skin: routine care to maintain acidic pH, maintain skin moisture ● Preventing secondary infection: use of PPE, safety precautions, Nursing Goals: ● Relief of pain ● Improve symptoms ● Enhance skin integrity ● Prevention of infection ● Promoting fluid balance Autograft: tissue obtained from patient’s own skin Allograft: tissue obtained from donor of same species Xenografts: tissue obtained from another species 6. Health promotion & patient teaching ● Educate patient on disease, prognosis, and important of treatment adherence ● Promote good habits for maintaining skin integrity: nutrition, hygiene, prevention of secondary infection, etc.Med Surg Exam 1Med Surg Exam 1 Nutrition and Care of Patient with Nutritional Disorders (Ch 4) 1. Nutritional assessment & tools Screening for older adults ● Health history, current issues/medications, family history, and clinical exam Clinical exam: General appearance (height and weight) Skin, hair, nails Mucous membranes Mouth - teeth, gums, and tongue Neck and thyroid Musculoskeletal (osteoporosis?) Abdomen ● Lifespan considerations: ○ Teen boys 1,600-3,200 calories/dayMed Surg Exam 1 ○ Teen girls calories/day ● BMI ● Waist circumference: tells us the distribution of fat ○ Excessive abdominal fat if men have 40 inches and women have 35 in circumference ○ High waist circumference puts patients at risk for: ■ Diabetes ■ Dislipidemia ■ Hypertension ■ Heart attack ■ Stroke ● Biochemical measurements ● Clinical findings ● Dietary data 2. Risk factors for nutritional problems ● Underlying diseases that results in impaired digestion, absorption, excretion, or storage of nutrients ● Older age: social isolation, cognitive impairment, polypharmacy, reduced functional status, financial instability, poor dental health, limited ability to shop and cook ● Adolescents need proper intake of vitamins and minerals for the development and growth ● Genetic predisposition ● Hospitalization- inadequate intake ● Physical impairments ● Cultural influences ● Medication/treatments Signs of nutritional problems: ● Muscle wasting ● Poor skin integrity ● Loss of subq tissue 3. Biometric assessment Serum prealbumin and albumin: used to find out protein deficiency ● ⇣ albumin levels could mean overhydration, liver or renal disease, excessive protein loss due to burns, major surgery, infection, or cancer. Serum transferrin and retinol-binding protein: protein that binds and carries iron from intestines via serum ● ⇣ faster than albumin levels in response to protein depletion ● ⇣ transferrin = ⇣ iron and synthesis of functioning hemoglobin anemia CBC: red blood cells, white blood cells, and platelets ● Tells us about iron and ability to complete metabolic processes. ● ⇣ lymphocytes in malnutrition Electrolytes: sodium, chloride, potassium, magnesium, phosphate, CO2Med Surg Exam 1 ● Can vary day to day ● Provide info about electrolyte balance and kidney function 24 hour urine collection: calculates the creatinine/height index that assesses metabolically active tissue and indicates degree of protein depletion. ● Calculated based on height and gender ● ⇣ values indicate loss of lean body mass and protein malnutrition ● Creatinine is the breakdown product of creatine phosphate from muscle and protein metabolism. 4. BMI Formula: kg/m^2 or lb/in^2 x 703 ● Estimation of body fat of a person ● Distribution of fat or body weight differs within ethnic groups ● Not a sole determinant of health or nutritional status ● Low BMI: poor nutritional status and increased mortality in hospitalized patients ● Increased lean body mass or large frame can increase BMI 5. Treatment/management of nutritional disorders ● Obesity is the leading risk factors for global deaths: contributes to diabetes, CAD, and cancer ● Fat tissue is inflammatory tissue which leads to more cytokines and cellular damage ● Disorders caused by nutritional deficiency are among the leading causes of illness and death in the US 6. Diets Methods of collecting dietary info: ● Food record: Patient keeps record of food consumed over a period of time (3-7 days) ● 24- hour food recall: recall all foods ate the day before and the quantities of each food. ● Dietary Interview: establish trust and respect. ○ Open ended questions ○ Determine how many servings and ask about ingredients ● Cultural and ethnic considerations: influences dishes, frequencies, ingredients, health and healing, expression of caringMed Surg Exam 1Med Surg Exam 1