Skin is the largest sensory organ of body with a surface area 15 to 20
square feet and a weight of about 9 lb.
Skin synthesis vitamin D3 which converts into calcitriol that is
biologically active form of vitamin-D (also known as
1,25-dihydroxycholecalciferol). The major role of vitamin-D for normal
metabolism of calcium and phosphate.
There are three Phage’s of wound healing: (a)Inflammatory: 3 to 5 days (b) Fibroblastic: begins 4th day after injury and last 2 to 4
weeks (c) Maturation: begins as early as 3 weeks after the injury and may last
for 1 year.
Commonly three methods are used to take skin biopsy are punch,
excisional and shave.
Skin biopsy for viral culture is placed on ice immediately.
Nurse obtain the culture sample before instituting antibiotics therapy.
In wood’s light examination the skin is viewed under UV light through a
special glass to identify superficial infection of skin.
Diascopy is a technique allows clearer inspection of lesion by
eliminating the erythema caused by increase blood flow to the area.
Herpez zoster / shingles is caused by varicella zoster virus.
Tzanck smear is used to diagnose the herpez. This test also used in
diagnosis of pemphigus, CMV infection.
Herpes simplex virus type 1 infection causes a cold sore usually on
lips and type 2 causes genital herpes both are contagious.
Erysipelas is an acute, superficial, rapidly spreading inflammation of
the dermis and lymphatics caused by streptococcus group A.
Cellulitis is a skin infection into the deeper dermis and subcutaneous
fat, the causative organism is usually streptococcus pyogenes.
After bites of Brown recluse spiders or black widow spider Ice is apply
to inhibit the enzyme activity of venom.
In frost bite nurse rewarm the affected body with warm water. Avoid the
using the dry heat, and never rub or massage the part which May result in
further tissues damage.
Actinic keratoses are caused by chronic exposure to the sun.
Over exposure to sun is primary cause of skin cancer.
Basal cell, squamous cell, or melanoma are the three main types of skin
cancer.
Melanoma is highly metastatic form of skin cancer.
Psoriasis is a chronic non-infectious skin inflammation involving
keratin synthesis that results in psoriasis patches.
Psoriasis vulgaris is common types of psoriasis.
Shedding silvery, white scales on a raised, reddened, round plaque is
common features of psoriasis.
Psoriasis plaque commonly seen scalp, knees, elbows, extensors surface
of arm and legs and sacral region.
In pressure ulcer avoid direct massage to a reddened skin area because
massage can damage the capillary beds and cause tissue necrosis.
Electrical stimulation of wound area, vacuum assisted wound closure,
hyperbaric oxygen therapy, or use of topical growth factors also use to treatment
of pressure ulcer.
In small burn the response of body to injury is localized.
Large burn consists of 25% or more of the total body surface area, and
response to injury is systemic.
Superficial thickness burn involves injury to the epidermis and mild to
severe erythema pink to red is present but no blisters. Burn is pain full or no
graft required.
Superficial partial thickness burn involves injury deeper into the
dermis. Mottled pink to red base and broken epidermis with a wet, shiny and
weeping surface is characteristic. Burn is pain full. Heal 10 to 21 days with
no scarring.
Deep partial thickness burn extends deeper into the skin dermis. Wound
surface is red and dry with white areas in deeper parts. Heal in 3 to 6 weeks
and skin graft may be necessary.
Full thickness burn cause injury to epidermis or dermis skin graft may
be necessary for healing. Wound appears waxy white, deep red, yellow, brown or
black.
Deep full thickness burn involves injury beyond the skin into
underlying fascia and tissue and muscles, bone and tendons. Injured area
appears black. Healing time take months.
Burn of the head, neck, and chest are associated with pulmonary
complications.
Burn of the face are associated with corneal abrasion.
Burn of the ear associated with articular chondritis.
Electrical burns result in internal tissue damage.
Initially in burn hyponatremia and hyperkalemia occur.
In burn hematocrit level increase as a result of plasma loss.
Phage’s of management of the burn injury: (a) Emergent phage/ Resuscitation phage: Begins at time of injury ends with
restoration of normal capillary permeability. Duration usually 48 to 72 hours. (b) Acute phage: begins when client is hemodynamically stable and diuresis
has begun. Focus on infection control, wound care, nutrition, pain management
or physical therapy. (c) Rehabilitation phage: overlaps acute phage of care and extends beyond
hospitalization.
For an inhalation injury administer 100% oxygen via tight fitting
non-rebreather face mask as prescribed until the carboxyhemoglobin level fall below
15%.
Parkland formula is used to calculate the amount of fluid required for
burn client.
Parkland formula = 4ml × kg × % of TBSA Burn (half of fluid is given
first 8 hour and half given in next 16 hours)
Nurse maintain 30 to 50 ml/ hr urine out-put in burn patient.
Diuretics increase the risk of hypovolemia in burn patient and
generally avoided as a means of decreasing edema.
Avoid administering medication by oral route in burn patient because of
the possibility of gestational dysfunction.
Nurse avoid administering IM or SC medication in burn patient because
absorption through the soft tissue is unreliable when hypovolemia and large fluid
shift occur.
In escharotomy a lengthwise incision is made through the burn eschar to
relive construction and pressure and to improve circulation. It is performed
usually in circumferential burn.
Escharotomy is performed at bedside without anesthesia because nerves
ending destroyed by burn.
In fasciotomy an incision is made extending through the subcutaneous tissue
and fascia under general anesthesia in OT.
There are two methods of Wound care in burn patient: (a) Open method: Antimicrobial cream apply on wound and wound is left open
in air without a dressing. (b) Close method: Gauze dressing are carefully wrapped from the distal to
proximal area of the extremity to ensure that circulation is not compromised.
Dressings will change every 8 to 12 hours.
In Hydrotherapy wound is cleaned by immersion, showering, or spraying
of burn patient.
Hydrotherapy normally perform by nurse for 30 minutes or less.
Debridement is the removal of eschar or necrotic tissue to prevent
bacterial proliferation under the eschar and promote wound healing. It may be
mechanical, enzymatic or surgical.
Types of wound covering: (a) Biological: Amniotic membrane, allograft / homograft
(human tissue), xenograft / Heterograft (animal tissue), cultured skin. (b) Artificial skin: it consists of two layer -Silastic
epidermis and porous dermis made from bovine hide collagen and shark cartilage. (c) Biosynthetic (d)Synthetic (e)Autograft
Autograft are immobilized following surgery for 3 to 7 days to allow
time adhere and attached to the wound bed.
After skin graft nurse elevate and immobilize the graft site and keep
the site free from pressure or avoid weight bearing.
Nurse instruct the client protect the grafted site from sun light.
Nurse keep the donor skin site clean, dry, and free from pressure or
prevent client from scratching the site.
Anti-burn scar support garments are usually prescribed to be worn 23
hours a day until the burn scar tissue has matured which takes 18 to 24 months.
Calamine lotion and burow’s solution is used to treat IVY poison.
Atopic dermatitis is inflammatory skin disease that is also known as
eczema and characterized by dry and scaly skin.
Treatment of actinic keratosis includes medication and therapy such as
cryotharapy, curettage, excision and laser therapy.
Sunscreens prevent the penetration of UV light and protect the skin.
Sunscreens provide protection both UVA &UVB.
For effective sunscreen it applied at list 30 minutes before sun
exposure.
Organic (chemical) sunscreen absorb the UV light and inorganic
(physical) reflects and scattered the light.
Sunscreens reapply every 2 to 3 hours for effectiveness.
The UV light is greatest between 10.00 am to 4.00 pm so protective
clothing and hat and sunglasses worn.
Tazarotene is vitamin A derivative drug used in psoriasis for topical
applications
Calcipoteriene is an analogue of vitamin D use in psoriasis for topical
applications.
Aciterin is vitamin A derivative used systemic therapy in psoriasis and
contraindicated in pregnancy because it embryotoxic and teratogenic.
iPLEDGE programme is risk management contraindications of Isotretinoin
in pregnant women.
Nitrofurazone, mafenide acetate and silver sulfadiazine are apply 1/16-inch
film directly to burn.
Silver sulfadiazine used primarily to prevent sepsis in client with
burn.
Isotretinoin elevate the triglycerides levels so nurse monitors its
level before and after therapy.
Oral contraceptive and spironolactone use to treat acne in female
client.
Adverse effects of spironolactone include breast tenderness, menstrual
irregularities and hyperkalemia.
Adenocarcinoma is a tumor that arises from glandular epithelial tissue.
Carcinoma are malignant tumor that orientated from epithelial cells,
skin, GI, lungs, uterus, breast, and other body organ.
Carcinoma in situ is a premalignant lesion with all the histological
characteristic of cancer except invasion of the basement membrane.
Nadir the period of time during which an antineoplastic medication has
its most profound effects on the bone marrow.
Sarcoma neoplasm that originates from muscle, bone, fat, lymph system
and connective tissue.
Undifferentiated cells are cells that have lost the capacity for
specialized function.
Routes of metastasis are local seeding, blood born and lymphatic
spread.
Grading a tumor classifies the cellular aspects of the cancer.
Staging classifies the clinical aspects of the cancer and degree of
metastasis at diagnosis.
The examples of viral carcinogen (oncovirus) are Epstein barr virus,
hepatitis B virus and human papilloma virus.
H pylori infection is associated with an increased risk of gastric
cancer.
Immunosuppressive individual has high risk to develop cancer such as HIV
client or who take immunosuppressive medication.
Breast self-examination perform monthly by a woman; normally 7 to 10
days after menses.
Biopsy is the definitive means of diagnosing cancer.
Prophylactic, curative, control (cytoreductive or debulking), palliative,
reconstructive or rehabilitative surgery is performed to improve the life of
cancer patient.
Severe cancer pain is treated with opioids such as codine sulfate,
morphine sulfate, methadone, hydromorphone hydrochloride.
Normal cells most profoundly affected in chemotherapy is skin, hair,
lining of GI tract, spermatocytes, and hematopoietic cells.
Common side effects of chemotherapy include fatigue, alopecia, nausea
and vomiting, mucositis, skin changes, myelosuppression (neutropenia, anemia
and thrombocytopenia).
Prefer route of chemotherapy is IV.
Common side effects of radiotherapy are local skin changes and
irritation, alopecia, fatigue, altered tests sensation.
Fatigue is the most common side effects of radiotherapy.
There are two main types of radiation therapy: (a) External beam radiation (teletherapy) (b) Internal radiation therapy (brachytherapy)
Brachytherapy includes an unsealed source or a sealed source of
radiation.
Unsealed source of radiation is administered via the oral or IV route
or by the instillation into body cavities.
Unsealed radiation therapy client excreta are radioactive that harmful
to others. Most of source is eliminating within 48 hours then after neither the
client nor the excreta are radioactive or harmful.
In sealed source of radiation, the client excreta are not radioactive.
The female client resumes sexual intercourse after 7 to 10 days if the
radiation implant was placed into the cervix.
Client avoid the exposure of irradiated area to the sun and heat
exposure.
Patient avoid rubbing the radiation site and it clean with warm water alone
or with mild soap and water.
Patient do not use the powder, ointment and lotion at radiation site without
prescription.
Nurse limit time to 30 minutes per care provider per shift with
radiotherapy client.
Nurse wear dosimeter film badge to measure radiation exposure.
Nurse wear a lead shield to reduce the transmission of radiation.
Nurse do not allow children younger than 16 years or pregnant women to
visit radiotherapy client.
Nurse limit the visitors to 30 minutes per day; visitors should be
stand at list 6 feet from the source.
Dislodged radiation implant client the nurse ensures that no linens or
other articles in the client’s room are disposed of, prohibited visitors and
notify the radiation oncologist.
BMT (bone marrow transplantation) and PBSCT (peripheral blood stem cell
transplantation) are procedure that replace stem cells that have been destroyed
by high doses of chemotherapy and radiation therapy.
BMT and PBSCT are most commonly used in treatment of leukaemia, lymphoma.
But it also used in neuroblastoma and multiple myeloma.
Allogeneic, syngeneic and autologous are types of stem cells donor.
The stem cells used in PBSCT come from the bloodstream in a 4 to 6
hours process called apheresis or leukapheresis.
Allogeneic marrow is transfused immediately and autologous marrow is
frozen for later use (cryopreservation).
Procedure of stem cell transplantation is harvest, conditioning,
transplantation, and engraftment.
Stem cells administer by central line, similar to blood transfusion or
by IV infusion or IV push.
Engraftment is the movement of stem cells to the site of marrow forming
site of recipient bone. Successful engraftment takes 2 to 5 weeks.
Failure to graft, graft versus host disease in allogeneic transplants
and veno-occlusive disease is the three main complications of BMT and PBSCT.
In Veno-occlusive disease occlusion of the hepatic venules occurs by
thrombosis or phlebitis.
Leukemia affects the bone marrow causing the anemia, leukopenia,
thrombocytopenia and decline immunity.
For leukemia client nurse maintains room high efficiency particulate
air filtration or a laminar airflow system if possible.
Nurse avoid invasive procedure such as injections, rectal temperature
and urinary catheterization in leukemia client.
Nurse avoid to give live vaccine to leukemia client such as MMR,
polio, varicella, shingles.
Infection is major cause of death in immunosuppressive client.
Client is risk for bleeding when the platelet count falls below 50000/
mm3 and spontaneous bleeding occur when the platelet count falls below
20000/mm3.
Leukemia client avoid contact sports and sharp objects activity.
Avoid aspirin intake because it increases the bleeding in leukemia
client.
Hodgkin's disease is a malignancy of lymph nodes. Cervical node affected
first mostly.
In Hodgkin's disease (lymphoma) reed Sternberg cells present in lymph
node.
Multiple myeloma is a malignant proliferation of plasma cells.
Abnormal plasma cells produced abnormal antibodies (myeloma protein or
Bence Jones protein)
Bone pain specially in the ribs, spine and pelvis is seen in multiple
myeloma.
The client with multiple myeloma is at risk for pathological fracture due
to bone reabsorption.
In multiple myeloma elevated calcium and uric acid level seen due to
damage of kidney.
In multiple myeloma urine analysis shows Bence Jones proteinuria and
elevated serum protein level.
Testicular cancer is two types: (a) Germinal tumors: Seminomas and Non-seminomas (b) Nongerminal tumors: Interstitial cell tumor or Androblastoma.
Monthly self-testicular examination is best method to detect testicular
cancer in early stage.
Painless testicular swelling and Dragging or pulling sensation is early
signs of testicular cancer.
Unilateral orchiectomy or radical orchiectomy (remove affected testis
spermatic cord and regional lymph node.
Testicular cancer mostly occurs between 15 to 40 years of age specially
in undescended testis.
Back and bone pain or respiratory symptoms are later sign of testicular
cancer.
Human papilloma virus infection, sex before 17 age, multiple sex
partners or male partners with multiple sex partners or smoking are the risk
factors of cervical cancer.
Painless vaginal postmenstrual and postcoital bleeding and foul
smelling or serosanguineous vaginal discharge are early signs of cervical cancer.
Treatment of cervical cancer: (a) Nonsurgical: chemotherapy, cryosurgery, radiotherapy and laser therapy. (b) Surgical: conization, hysterectomy and pelvic exenteration.
In cryosurgery involves freezing of the cervical tissue by probe with
subsequent necrosis and sloughing.
After cryosurgery a heavy watery discharge will occur for several
weeks.
In conization a cone shape area of cervix is remove.
Pelvic exenteration is the removal of all pelvic content including
bowel, vagina, and bladder.
Avoid strenuous activity after hysterectomy and pelvic exenteration.
Nurse assess the bleeding after following hysterectomy and pelvic
exenteration.
Ovarian cancer grows rapidly, spread fast and is often bilateral.
An exploratory laprotomy is performed to diagnose and stage the
disease.
Elevated tumor marker CA- 125 is seen in ovarian cancer.
Abnormal bleeding specially in postmenopausal women is early signs of
endometrial cancer.
Breast cancer metastasis occurs via lymph nodes.
Common site of metastasis of breast cancer is bone and lungs.
In breast cancer a mass usually felt in the upper outer quadrant,
beneath the nipple or in axilla.
BSE (Breast self examination) is the method of early detection of breast cancer.
Hormone drug therapy for breast cancer or ovarian cancer is used for
postmenopausal women.
Lumpectomy, simple mastectomy and modified mastectomy are surgical
intervention of breast cancer.
In lumpectomy tumor excised and remove or lymph node dissection are also
performed.
In simple mastectomy breast tissue and nipple are removed and lymph
node usually remain intact.
Modified radical mastectomy breast tissue, nipple and lymph node are
removed and muscles are left intact.
Nurse position the client after mastectomy in semi-Fowler position turn
from back to the unaffected side with the affected arm elevated above the level
of heart to promote drainage and prevent lymphedema
No IV infusion, no injection, no blood pressure measurement and no venipuncture
is done in affected arm on side of the mastectomy. Avoid trauma of affected arm.
Avoid affected arm over use or don't carry pocket book and do not let
the affected arm hang dependent after mastectomy.
Helicobacter pylori infection, a diet of smoked food, highly salted,
processed or spiced foods have carcinogenic effects in gastric cancer.
Indigestion, abdominal discomfort, full feeling, epigastric, back or
retrosternal pain are early signs of gastric cancer.
Bland diet is given in gastric cancer client.
Do not irrigate nasogastric tube by the nurse after gastrectomy. Nurse
assist the physician to irritation and remove.
Surgical intervention in gastric cancer: (a) Subtotal gastrectomy: Biliroth I: (Also called gastroduodenostomy) Partial gastrectomy with remaining segment
anastomosed to the duodenum. Biliroth II: (Also called gastrojejunostomy) Partial gastrectomy with remaining segment
anastomosed to the jejunum. (b) Total gastrectomy: (Also called esophagojejunostomy) Removal of the stomach with attachment of
the oesophagus to the jejunum or duodenum.
Most pancreatic tumors are highly malignant and originating from the
epithelium of the ductal system.
Endoscopy retrograde cholangiopancreatography is performed to diagnose
pancreatic cancer.
Clay coloured stools, nausea and vomiting, jaundice, unexplained weight
loss, glucose intolerance and abdominal pain are sign of pancreatic cancer.
Whipple procedure is performed in pancreatic cancer which involves a
pancreaticoduodenectomy with removal of the distal third of stomach,
pancreaticojejunostomy, gastrojejunostomy, and choledochojejunostomy.
Age older than 50, familial polyposis, and family history of colorectal
cancer is risk of intestinal tumor.
Blood in stool is most common manifestation of intestinal cancer.
Abnormal stool in intestinal cancer: (a) Ascending colon tumor: Diarrhoea (b) Descending colon tumor: Constipation or some diarrhoea. (c) Rectal tumor: Alternating constipation and diarrhoea.
Bowel perforations with peritonitis is main complications of intestinal
cancer.
Early sign of intestinal obstruction is increase peristaltic activity
and late sign are hypo active bowel sound.
Before colostomy client eat low fibre diet for 1 to 2 days and
administer laxatives or enema.
Intestinal antiseptic and antibiotics prescribed to decrease bacterial
content to reduce risk of infection in intestinal surgery or colostomy.
Nurse empty the colostomy pouch when it one third is full.
Normal colostomy stoma color is red or pink indicating high vascularity.
A pale pink stoma indicates low hemoglobin and hematocrit level.
Nurse expect liquid stool from an ascending colon colostomy; loos to
semi formed stool from a transverse colon colostomy; close to normal stool from
a descending colon.
Client with colostomy avoid food that cause excessive gas formation and
odour.
A dark blue, purple or black stoma indicates compromised circulation,
required physician notification.
In ileostomy post-operative drainage will be dark green and progress to
yellow as client begins to eat.
After ileostomy the client is at risk for electrolyte imbalance and
dehydration.
Nurse do not administer medication such as suppositories through
ileostomy.
After ileostomy the stool is liquid.
Airway is the priority for a client with lung or laryngeal cancer.
Client with lung cancer place on fowler’s position for easy breathing.
Smoking active and passive or exposure to environment pollution is risk
factors of lungs cancer.
Cigarette smoking and heavy alcohol consumption exposure to pollutants
asbestos, wood dust or exposure to radiation is risk factors of laryngeal cancer.
0 Comments