Integumentary and Sensory

Severe itching which is subjective data a symptom of skin problem or general disease process (Cancer, jaundice or DM)


Tx: Antipruitics (Benedryl), therapeutic baths.

Gross swelling of lips, eyes, larynx. (Which can lead to resp. distress)

Tx: antihistamines, Epinephrine

Small vesicles of red, itchy skin, vesicles burst, ooze and crust forms.

Cause by stress, hereditary, allergies, irritant contact, etc.

Tx: antihistamines, wet dressings, bath, anti-inflammatory

Parasites move from person to person and are mostly found between fingers and toes. (burrows in the skin)

Causes severe itching which can become infected

Tx: Kwell lotion/shampoo

caused by chicken pox virus (Varicella)

s/s: pruritis, intense pain, malaise and usually affects only one side of the body (rash lasts 3-4 days)

CONTACT ISOLATION

Fever blisters and cold sores that last up to a week

CONTACT ISOLATION

Dry flakes on scalp or cheese-like plugs

Tx: Shampoos (Selsan Blue)

Excess sebacious drainage, scales, or cheese-like plugs on the body.

s/s: yellowish greasy scales.

Tx: no cure; steroids, low FAT diet, sunlight, exercise.

no known cause

s/s: red patches-silvery scales-that shed constantly


Tx: wet drgs, salicylic acid, steroids, sun, Vit A

Inflammation of the skin where two surfaces touch. (ex: axillary, abdomen, legs, etc)

Tx: decrease friction, keep clean

fungal infection casued by yeast (mouth, vagina,colostomy site)

Tx: antifungal cream, wet compress, Nystatin.

small flesh/brown colored papules cause by HPV.

Tx: ketolytic agents, liquid nitrogen, electrodesication (scrape and suction)

Cluster of boils

Tx: warm wet dressing, lance.

• Asymmetry
• Borders (irregular)
• Color (uneven)
• Diameter (large)

• head = 9%
• ant/post torso =36%
• ant/post arms (both)= 18%
• groin = 1%
• ant/post legs (both) = 18%

burns the epidermis and causes the dermis to swell

Superficial partial- burns the first and second layer of skin

Deep partial- burns deeper skin layers

Injures all layers of the skin and the tissue underneath.


Can destroy fats and muscles.

burns extend thru the skin down to the muscles, ligaments, tendons, blood vessels and bones.

Seen in nuclear radiation and usually fatal

• 1. neurogenic shock (airway)
• 2. fluid loss (foley and I&O's)
• 3. infection
• 4. repair (graft)

• Silvadene
• Silver Nitrate
• Debridement
• Grafting
• Diet high in CAL, PRO, Vit C

• Infection
• G.I. disturbance
• Hypostatic pneumonic
• Kidney failure
• Anemia
• Decubitus
• Contractures
• Low Self- Esteem

Affects the bone in the middle ear; sound waves are blocked as they move thru the auditory canal or middle ear and cant reach the inner ear. (cause by disease or malformation/damage to outer or inner ear).

s/s: muffle or faint sound, may have earache or discharge.

Sound waves are conducted normally, but the messages are not transmitted properly to the brain. (caused by head injuries, old age, loud noises, hereditary, etc.)

s/s: sounds are muffled or distorted, high tones are inaudible, dizziness or nausea and ringing or buzzing noise.

Sound signals are transmitted normally but interupted incorrectly by the brain (caused by damage or malfuction to the brain).


s/s: communication difficulties, difficulty hearing speech in a noisy enviroment

temp is 98.6; aseptic technique unless tympanic membrane is damaged

pt should lie on the affected side for 5 minutes (fluid should flow from gravity)

feeling of being "rotated" when you are not. (caused by viral infection, otitis media, migraine, labrynthitis, stroke, tumor or MS)


s/s: dizziness, N/V

Tx: –Antibiotics, Antivert, Klonopin, Phenergran, Radiation or Surgery

Chronic external ear inflammation caused by prolonged exposure to water.

• Tx: Antibiotics, antifungals, ear plugs
• Prevention: Acetic Acid (Alcohol/Vingear solution)

Occurs in warm, damp climates especially when auditory canal hasn't been completely dried; fungus grows

Tx: ear drops, antifungal meds, alcohol and glycerin, long term treatment

caused by extremely loud noises, internal infection and increased pressure.

Tx: depends on the amount of damage, heals spontaneously or myringotomy

Fluid collects in the middle ear as a result of obstruction of Eustachian Tube (infection, allergy, tumor or change in altititude)

s/s: crackling sensation, fullness in ear or hearing loss

Tx: myringotomy

Pus collects in the tympanic membrane

s/s: inflamed or bulging tympanic membrane, fever, HA, hearing impaired.

Tx: myringotomy to prevent rupture of eardrum.

• 1. can lead to otitis media
• 2. mastoiditis
• 3. meningitis
• 4. brain abscess

Associated with punctured ear drum or complications of acute otitis media.

s/s: ringing of the ear, drainage, HA, N/V, pain, increased temp, chills and dizziness.

Tx: antibiotics and mastoidectomy may be necessary

A surgical incision is made into the tympanic membrane to drain the fluid from the ear and tubes are placed in the ear to drain excess fluid which releases pressure and pain.

Post op: small cotton ball in ear (do not plug tightly), antibiotics, rest and adequate diet

placed in eardrums and allows continuous drainage from the middle ear.

post op: do not put water into ears.

Reconstruction of the middle ear to preserve vital parts with less impairment of hearing (reconstruction of bones).

done instead of radical mastoidectomy

bony fixations of stapes which interfers with vibrations of stapes.

s/s: tinnitus, slow loss of hearing

Tx: surgery (stapidectomy)

Stapes removed and replaced by a small piece of wire or plastic piston

post op: watch for injury potential, do not blow nose violently, no water in ears, back to normal activity in 2 weeks.

Removal of infected mastoid cells and to ensure drainage. (mastoid bone contains facial nerve and inner ear).

Constructing a new window to replace natural window that connects the middle ear to the inner ear so that vibrations can be carried.

post op: instruct pt to move slowly (may have N/V), hearing takes 4-6 weeks to improve and avoid blowing nose.

Disturbance of semi-circular canals in the inner ear (cause is excess fluid).

s/s: vertigo, n/v, fall risk, hearing loss, tinnitus and aural fullness

Tx: Benadryl, Dramamine, antihistamine, antiemetic, sedatives, tranquilizers, bedrest, low Na diet, fluid restriction, omit ETOH, caffeine and smoking.

Chronic inflammatory process of the eyelid (common cause is bacteria, Staph, allergies)

s/s: red inflammed crust like scales at the base of the lid, may or may not burn or itch.

Tx: no cure; keep eyelids clean, warm compress, topical antibiotic ointment

Infection of the eyelid that starts at the hair follicle or sebacious gland.

s/s: pain, red, swelling, rupture with discharge.

Tx: usually clears up on own, don't touch, hot wet compress, antibiotics,

inflammation of conjunctiva (spread by droplet)

s/s: pain, redness, swelling, lacrimation

Tx: hot moist compress, no corticosteroids and do not cover.