SKIN
• Largest organ of the body
• Functions:
Protection
Sensation
Fluid balance
Temperature regulation
Vitamin D production
Immune response
Plaque
• Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter
• e.g.Psoriasis, seborrheic and actinic keratoses, eczema
Wheal
• Elevated irregular-shaped area of cutaneous edema; solid, transient, variable diameter
• Ex. Insect bite, urticaria, allergic reaction
Nodule
• Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 to 2 cm in
diameter
• Ex. Dermatolfibroma, erythema nodosum, lipomas, melanoma, hemangioma,
neurofibroma
Tumor
• Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis;
greater than 2 cm in diameter
• Ex. Neoplasma, lipoma, hemangioma
Vesicle
• Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1
cm in diameter
• Ex. Varicella (chickenpox, herpes zoster, impetigo, acute eczema)
Bulla
• Vesicle greater than 1 cm in diameter
• Ex. Blister, lupus, impetigo, drug reaction
Pustule
• Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid
• Ex. Impetigo, acne, folliculitis, herpes simplex
Cyst
• Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with
liquid or semisolid material
• Ex. Sebaceous cyst, cystic acne
SKIN CONFIGURATIONS
Secondary Skin Lesions
Scale
• Heaped-up keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in
size
• Ex. Seborrheic dermatitis following scarlet fever
Lichenification
• Rough, thickened epidermis secondary to persistent rubbing, itching or skin irritation;
often involves flexor surface of extremity
Scar
• Thin to thick fibrous tissue that replaces normal skin following injury or laceration to the
dermis
Keloid
• Irregular-shaped elevated, progressively enlarging scar, grows beyond the boundaries of
the wound; caused by excessive collagen formation during healing
Excoriation
• Loss of the epidermis linear hollowed-out crusted area
• Ex. Abrasion or scratch scabies
Fissure
• Linear crack or break from the epidermis to the dermis, may be moist or dry
• Ex. Athlete’s foot, cracks at the corner of the mouth, eczema
Erosion
• Loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or
bulla
• Ex. Varicella, variola after rupture, candidiasis, herpes simplex
Ulcer
• Loss of epidermis and dermis, concave; varies in size
• Ex. Decubiti, stasis ulcers, syphillis chancre
Atrophy
• Thinning of the skin surface and loss of skin markings; skin appears translucent and
paperlike
• Ex. Aged skin, striae, discoid lupus erythematosus
Telangiectasia
• Fine, irregular red lines produced by capillary dilation
• Ex. Vascular spider, lupus erythematosus
Cherry Angioma
• Small, slightly raised, bright red areas that appear on the face, neck and trunk of the body.
These increase in size and number with advanced age.
Skin Appearance
Cyanosis Jaundice
Normal Aging Changes
• Thinning of skin
• Uneven pigmentation
• Wrinkling, skin folds, and decreased elasticity
• Dry skin
• Diminished hair
• Increased fragility and increased potential for injury
• Reduced healing ability
• Prepare the patient: explain the purpose and provide privacy and coverings
• Ask assessment questions
• Inspect the patient’s entire body including mucosa, scalp, hair, and nails
• Wear gloves
• Assess any lesions; palpate and measure them
• Note hair distribution
• Photographs may be used to document nature and extent of skin conditions and to
document progress resulting from treatment; they may also be used to track moles
Diagnostic Procedures
• Skin biopsy
• Immunofluorescence
• Patch testing
• Skin scrapings
• Tzanck smear
• Wood’s light examination
Causes:
1. dry heat - fire
2. moist heat - steam or hot liquids
3. Radiation
4. friction
5. heated objects
6. the sun
7. Electricity
8. or chemicals
Classification of Burns
➢ Manifestations:
skin is bright red and blotchy
Blisters. It usually looks wet because of the loss of fluid through the
damaged skin.
very painful
➢ Skin with a third-degree burn may appear white or black and leathery on the
surface.
➢ Because the nerve endings in the skin are destroyed, the burned area may not be
painful, but the area around the burn may be extremely painful.
➢ Pain causes the breathing rate and pulse to increase.
➢ Some areas of the burn may appear bright red, or may blister.
➢ Electrical burns damage the deep tissues. Often only the area of the skin where
the electricity entered the body looks black and charred. Electrical shocks can
make a person stop breathing and interrupt the rhythm of the heart.
➢ Shock occurs when loss of fluids causes the blood pressure to become so low that
not enough blood reaches the brain and other major organs.
The symptoms of shock :
a. fainting, general weakness, nausea and vomiting, rapid pulse and
breathing, a blue tinge to the lips and finger nails, and pale, cold,
moist skin.
b. If the victim has been burned in a fire and has been exposed to
large amounts of smoke, he or she may also have chest pain, red
and burning eyes, and a cough.
c. All third-degree burns require emergency medical treatment.
Estimation of Total Body Surface Area (TBSA) Burned
Rule of Nines
Pathophysiology of Burns
• Burns are caused by a transfer of energy from a heat source to the body.
• Thermal (includes electrical)
• Radiation
• Chemical
Physiologic Changes
1. Make sure that the person is no longer in contact with smoldering materials. However,
DO NOT remove burnt clothing that is stuck to the skin.
2. If breathing has stopped, or if the person's airway is blocked, open the airway. If
necessary, begin CPR.
3. Cover the burn area with a cool, moist sterile bandage (if available) or clean cloth. A
sheet will do if the burned area is large. DO NOT apply any ointments. Avoid breaking
burn blisters.
4. If fingers or toes have been burned, separate them with dry, sterile, non-adhesive
dressings.
5. Elevate the body part that is burned above the level of the heart. Protect the burnt area
from pressure and friction.
6. Take steps to prevent shock. Lay the person flat, elevate the feet about 12 inches, and
cover him or her with a coat or blanket. However, DO NOT place the person in this shock
position if a head, neck, back, or leg injury is suspected or if it makes the person
uncomfortable.
• Rehabilitation is begun as early as possible in the emergent phase and extends for a long
period after the injury.
• Focus is upon wound healing, psychosocial support, self-image, lifestyle, and restoring
maximal functional abilities so the patient can have the best-quality life, both personally
and socially.
• The patient may need reconstructive surgery to improve function and appearance.
• Vocational counseling and support groups may assist the patient.
• Maintain BP above 100 mm Hg systolic and urine output of 30-50 mL/hr. Maintain serum
sodium at near-normal levels.
• Consensus formula
• Evans formula
• Brooke Army formula
• Parkland Baxter formula
• Hypertonic saline formula
• Note: Adjust formulas to reflect initiation of fluids at the time of injury.
• Generalized dehydration
• Reduced blood volume and hemoconcentration
• Decreased urine output
• Trauma causes release of potassium into extracellular fluid: hyperkalemia
• Sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia
• Metabolic acidosis
Acute Phase
Pain Management
• Analgesics
➢ IV use during emergent and acute phases
➢ Morphine
➢ Fentanyl
➢ Other
• Decrease level of anxiety
• Decrease/avoid sleep deprivation
• Non-pharmacologic measures
Nutritional Support
• Goal of nutritional support is to promote a state of nitrogen balance and match nutrient
utilization.
• Nutritional support is based on patient’s preburn status and % of TBSA burned.
• Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional
status with lower risk of aspiration in a patient with poor appetite, weakness, or other
problems.
Nursing Process: Care of the Patient in the Emergent Phase of Burn Care
Diagnosis
• Impaired gas exchange
• Ineffective airway clearance
• Fluid volume deficit
• Hypothermia
• Acute pain
• Anxiety
Extraocular Muscles
Visual Pathways
Cross-Section of the Eye Internal Structures of the Eye
Assessment and Evaluation of Vision
• Ocular history
• Visual acuity
➢ Snellen chart
Record each eye
20/20 means the patient can read the “20” line at a distance of 20 feet
• Finger count or hand motion
Diagnostic Evaluation
• Ophthalmoscopy
➢ Direct and indirect
➢ Examines the cornea, lens, and retina
• Slit-lamp examination
• Color vision testing
• Amsler grid
• Ultrasonography
• Fluorescein and indocyanine green angiography
• Tonometry
➢ Measures intraocular pressure
• Gonioscopy
➢ Visualizes the angle of the anterior chamber
• Perimetry testing
➢ Evaluates field of vision
➢ Scotomas: blind areas in the visual field
Impaired Vision
• Refractive errors
➢ Can be corrected by lenses that focus light rays on the retina
• Emmetropia: normal vision
• Myopia: nearsighted
• Hyperopia: farsighted
• Astigmatism: distortion due to irregularity of the cornea
Glaucoma
• A group of ocular conditions in which damage to the optic nerve is related to increased
intraocular pressure (IOP) caused by congestion of the aqueous humor
• Open-angle glaucoma
➢ Chronic open-angle glaucoma
➢ Normal-tension glaucoma
➢ Ocular hypertension
• Angle-closure (pupillary block) glaucoma
➢ Acute angle-closure
➢ Subacute angle-closure
➢ Chronic angle-closure
• Congenital glaucomas and glaucoma secondary to other conditions
Pathophysiology of Glaucoma
• Normal outflow of aqueous humor
• In glaucoma, aqueous production and drainage are not in balance
• When aqueous outflow is blocked, pressure builds up in the eye
• Increased IOP causes irreversible mechanical and/or ischemic damage
Clinical Manifestations
• Called the “silent thief,” glaucoma renders the patient unaware of the condition until
there is significant vision loss, including peripheral vision loss, blurring, halos, difficulty
focusing, and difficulty adjusting eyes to low lighting
• Patient may also experience aching or discomfort around the eyes or a headache
Diagnostic Findings
• Tonometry to assess IOP
• Gonioscopy to assess the angle of the anterior chamber
• Perimetry to assess vision loss
• Goal is to prevent further optic nerve damage
• Maintain IOP within a range unlikely to cause damage
• Pharmacologic therapy
• Surgery
➢ Laser trabeculoplasty
➢ Laser iridotomy
➢ Filtering procedures
➢ Trabeculectomy
➢ Drainage implants or shunts
Nursing Management
• Focus on maintaining the therapeutic regimen for lifelong control of a chronic condition
• Emphasize the need for adherence to therapy and continued care to prevent further vision
loss
• Provide education regarding use and effects of medications
• Medications used for glaucoma may cause vision alterations and other side effects; the
action and effects of medications need to be explained to promote compliance
• Provide support and interventions to aid the patient in adjusting to vision loss/potential
vision loss
Cataracts
Surgical Management
• If reduced vision does not interfere with normal activities, surgery is not needed
• Surgery is performed on an outpatient basis with local anesthesia
• Surgery usually takes less than 1 hour and patients are discharged soon afterward
• Complications are rare
Nursing Management
• Preoperative care
➢ Usual preoperative care for ambulatory surgery
➢ Dilating eye drops or other medications as ordered
• Postoperative care
➢ Provide written and verbal instructions
➢ Instruct patient to call physician immediately if: vision changes; continuous
flashing lights appear; redness, swelling, or pain increase; type and amount of
drainage increases; or significant pain is not relieved by acetaminophen
Corneal Disorders
LASIK
Retinal Disorders
• Retinal detachment
• Retinal vascular disorders
Central retina vein occlusion
Branch retinal vein occlusion
Central retinal vein occlusion
Macular degeneration
Retinal Detachment
• Separation of the sensory retina and the retinal pigment epithelium (RPE)
• Manifestations: sensation of a shade or curtain coming across the vision of one eye,
bright flashing lights, and sudden onset of floaters
• Diagnostic findings: assess visual acuity; assess retina by indirect ophthalmoscope, slit-
lamp, stereo fundus photography, and fluroescein angiography; tomography and
ultrasound may also be used
Surgical Treatment
• Scleral buckle
• Pars plana vitrectomy
Removal of the vitreous, locating the incisions at the pars plana
Frequently used in combination with other procedures
• Pneumatic retinopexy
Injected gas bubble, liquid, or oil is used to flatten the sensory retina against the
RPE
Postoperative positioning is critical
Nursing Management
• Patient teaching
Eye surgery is most often done as an outpatient procedure, so patient education is
vital
➢ Teach the signs and symptoms of complications, especially increased IOP
and infection
• Promote comfort
• Patient may need to lie in a special position with pneumatic retinopexy
Macular Degeneration
Nursing Management
• Patient teaching
• Supportive care
• Safety promotion
• Recommendations include improving lighting, getting magnification devices, and
referring patient to vision center to improve/promote function
Trauma
• Emergency treatment
Flush chemical injuries
Do not remove foreign objects
Protect using metal shield or paper cup
• Potential exists for sympathetic ophthalmia, causing blindness in the uninjured eye with
some injuries
Ophthalmic Medications
• Ability of the eye to absorb medication is limited
• Barriers to absorption include the size of the conjunctival sac; corneal membrane barriers;
blood–ocular barriers; and tearing, blinking, and drainage
• Intraocular injection or systemic medication may be needed to treat some eye structures
or to provide high concentrations of medication
• Topical medications (drops and ointments) are most frequently used because they are
least invasive, have fewest side effects, and permit self-administration
• Topical anesthetics
• Mydriatics (dilate) and cycloplegics (paralyze)
• Contraindicated with narrow angles or shallow anterior chambers and for inpatients on
monoamine oxidase inhibitors or tricyclic antidepressants
May cause CNS symptoms and increased BP especially in children and the
elderly
• Anti-infective medications
Antibiotic, antifungal, and antiviral products
• Medications used for glaucoma
Increase aqueous outflow or decrease aqueous production
May constrict the pupil and affect ability to focus the lens of the eye; affects
vision
May also may produce systemic effects
• Anti-inflammatory drugs; corticosteroid suspensions
Side effects of long-term topical steroids include glaucoma, cataracts, and
increased risk of infection; to avoid these effects, oral NSAID therapy may be
used as an alternate to steroid use
• Low vision
Visional impairment that requires devices and strategies in addition to corrective
lenses
Best corrected visual acuity (BCVA) of 20/70 to 20/200
• Blindness
BCVA of 20/400 to no light perception
Legal blindness is BCVA that does not exceed 20/200 in better eye, or widest field
of vision is 20 degrees or less
• Impaired vision often is accompanied by functional impairment
Management
• Support coping strategies, grief processes, and acceptance of visual loss
• Strategies for adaptation to the environment
Placement of items in room
“Clock method” for trays
• Communication strategies
• Collaboration with low vision specialist, occupational therapy, or other resources
• Braille or other methods for reading/communication
• Use of service animals
Assessment
• Inspection of the external ear
• Otoscopic examination
• Gross auditory acuity
• Whisper test
• Weber test
• Rinne test
• Otoscope
Otoscope Weber
Rinne Test
Speech Discrimination
Diagnostic Evaluation
• Audiometry
• Tympanogram
• Auditory brain stem response
• Electronystagmography
• Platform posturography
• Sinusoidal harmonic acceleration
• Middle ear endoscopy
Hearing Loss
• Increased incidence with age: presbycusis
• Risk factors include exposure to excessive noise levels
• Types
1. Conductive: due to external middle ear problem
2. Sensorineural: due to damage to the cochlea or vestibulocochlearnerve
3. Mixed: both conductive and sensorineural
4. Functional (psychogenic): due to emotional problem
• Manifestations:
Early symptoms include:
➢ Tinnitus: perception of sound; often “ringing in the ears”
➢ Increased inability to hear in a group
➢ Turning up the volume on the TV
• Impairment may be gradual and not recognized by the person experiencing the loss
• As hearing loss increases, patients may experience deterioration of speech, fatigue,
indifference, social isolation, or withdrawal; for other symptoms see
Hearing impairment: Mild, moderate, severe, or profound
Consequences
➢ Depends on age and severity
➢ <3 years: Affects language development; communication and safety
• Medical Management
Hearing aids; sign language; speech reading
Technologic devices (TDDs)
Use of products to perceive sound: Light-activated alarms; hearing dogs
• Surgical Management
Cochlear implant
Bone conduction device
Semi-implantable hearing aid
Guidelines for Communicating With the Hearing Impaired
Impacted Cerumen
• Pathophysiology and Etiology
Interferes with sound carried on airwaves
• Assessment Findings
Otalgia; diminished hearing; orange-brown accumulation of cerumen
• Medical Management
Hydration; irrigation or removal with cerumen spoon
Gentle irrigation should be used with lowest pressure, directing stream behind the
obstruction
➢ Glycerin, mineral oil, half-strength H2O2 or peroxide in glyceryl may help
soften cerumen
• Nursing Management
Inspects ear and implements measures to remove excessive cerumen
Ear drops; irrigation
➢ Proper administration and precautions
• Warm ear drops
• Avoid inserting syringe too deeply
• Direct the flow toward the roof of the canal
External Otitis
• Pathophysiology and Etiology
Overgrowth of pathogens
Infected hair follicle
• Assessment Findings
Red tissue; swelling
Reduced hearing; fever
Enlarged lymph nodes behind ear
Otoscope examination; C and S results
• Medical Management
Warm soaks; analgesics; antibiotics
Therapy is aimed at reducing discomfort, reducing edema, and treating the
infection
A wick may be inserted into the canal to keep it open and to facilitate medication
administration
Disorders of the External Ear: Foreign Objects
Otitis Media
• Assessment
Vital signs; monitoring for complications, drainage from affected ear, level of
discomfort; report elevation in temperature
• Diagnosis, Planning, and Interventions
Impaired comfort; risks: Injury; infection
• Interventions
Reduce anxiety
➢ Reinforce information and patient teaching
➢ Provide support and allow patient to discuss anxieties
Relieve pain
➢ Medicate with analgesics for ear discomfort
➢ Occasional sharp, shooting pains may occur as the Eustachian tube opens
and allows air into the middle ear; constant throbbing pain and fever may
indicate infection
Prevent injury
➢ Implement safety measures such as assisting with ambulation
➢ Provide antiemetics or antivertigo medications
• Improve communication and hearing
Hearing may be reduced for several weeks following surgery due to edema,
accumulation of blood and fluid in the middle ear, and dressings and packings
Use measures to improve hearing and communication as discussed in
“Communicating With the Hearing Impaired”
• Preventing infection
Monitor for signs and symptoms of infection
Administer antibiotics as ordered
Prevent contamination of ear with water from showers, washing hair, etc.
Ménière’s Disease
• Abnormal inner ear fluid balance caused by malabsorption of the endolymphatic sac or
blockage of the endolymphatic duct
• Manifestations:
fluctuating, progressive hearing loss; tinnitus; feeling of pressure or fullness; and
episodic, incapacitating vertigo that may be accompanied by nausea and vomiting
• Pathophysiology and Etiology
Malabsorption of fluid in the endolymphatic sac
• Treatment
Low-sodium diet, 2000 mg a day
Meclizine (Antivert), tranquilizers, antiemetics, and diuretics
Surgical management to eliminate attacks of vertigo; endolymphatic sac
decompression; middle and inner ear perfusion; and vestibular nerve sectioning
• Nursing Management
History: Symptoms; medical; drug; allergy
Assess gross hearing; Weber and Rinne tests
Provide emotional support; administer prescribed drugs; limit movement;
promote safety
Client teaching: Treatments
Acoustic Neuroma
• Assessment Findings
Gradual hearing loss; impaired facial movement
Altered facial sensation; tinnitus
Vertigo with or without balance disturbance
MRI; CSF studies
• Medical and Surgical Management
Surgical removal of tumor
Retain cranial nerve VIII function
Complications of surgery
• Nursing Management
Assessment: Evaluating hearing function
Observing the client’s facial movements
Testing for facial sensation
Postoperative care: Continue preoperative assessment data; monitor for IICP
Maintain strict asepsis
• Pharmacologic Considerations
Nonprescription preparations are available for softening hardened cerumen
➢ Refer client to a physician if hearing remains diminished
Be aware of potentially ototoxic effects of certain medications
Monitor the prescribed dosages and the client for signs of impaired hearing
General Considerations
• Gerontologic Considerations
Older clients
➢ Form drier cerumen; experience an increased incidence of impaction in the
external acoustic meatus
➢ Experience disorientation and confusion in strange surroundings
Hearing loss is common as adults age
Assess client’s ability to care for and maintain hearing aid or other treatments