NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Integumentary System

Focus topic: Medical–Surgical Nursing

The integumentary system comprises the enveloping membrane, or skin, of the body and includes the epidermis, the dermis, and all the derivatives of the epidermis, such as hair, nails, and various glands. It is indispensable for the body, as it forms a barrier against the external environment and performs many vital body functions.

Medical–Surgical Nursing: Anatomy and Physiology

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Skin

Focus topic: Medical–Surgical Nursing

Definition: The organ that envelops the body. It accounts for approximately 15% of the body weight and forms a barrier between the internal organs and the external environment.

Characteristics
A. Consists of three layers: epidermis, dermis, and subcutaneous.
B. It is the largest sensory organ, equipped with nerves and specialized sensory organs sensitive to pain, touch, pressure, heat, and cold.
C. Chief pigment is melanin, produced by basal cells.
D. Functions of skin.

  • Protection.
  • Temperature regulation.
  • Sensation.
  • Storage.

Bacterial Flora on the Skin
A. Normally present in varying amounts are coagulase-positive Staphylococcus, coagulase-negative Staphylococcus, Mycobacterium, Pseudomonas, diphtheroids, nonhemolytic Streptococcus, and hemolytic Streptococcus (group A).
B. The organisms are shed with normal exfoliation of skin; bathing and rubbing may also remove bacteria.
C. Damaged areas of skin are potential points of entry for infection.

Medical–Surgical Nursing

Medical–Surgical Nursing: Hair

Focus topic: Medical–Surgical Nursing

Definition: A threadlike structure developed from a papilla in the corium layer.
A. Hair goes through cyclic changes: growth, atrophy, and rest.
B. Melanocytes in the bulb of each hair account for color.
C. All parts of the body except the palms, soles of the feet, distal phalanges of fingers and toes, and penis are covered with some form of hair.

Medical–Surgical Nursing: Sweat Glands

Focus topic: Medical–Surgical Nursing

Definition: Aggregations of cells that produce a liquid (perspiration) having a salty taste and a pH that varies from 4.5 to 7.5.
A. Eccrine sweat glands.

  • Located in all areas of the skin except the lips and part of the genitalia.
  • Open onto the surface of the skin.
  • Activity controlled by the sympathetic nervous system.
  • Secrete sweat (perspiration).
    a. The chief components of sweat are water, sodium, potassium, chloride, glucose, urea, and lactate.
    b. Concentrations vary from individual to individual.

B. Apocrine sweat glands.

  • Located in the axilla, genital, anal, and nipple areas.
  • Located in ear and produce ear wax.
  • Develop during puberty.
  • Respond to adrenergic stimuli.
  • Produce an alkaline sweat.

Sebaceous Glands
A. Develop at base of hair follicle.
B. Secrete sebum.
C. Hormone controlled. Increased activity with androgens; decreased activity with estrogen.

System Assessment
A. Assess color.

  • Assess color of skin, including deviations from the normal range within the individual’s race.
    a. Use a nonglare daylight or 60-watt bulb.
    b. Note especially the bony prominences.
    c. Observe for pallor (white), flushing (red), jaundice (yellow), ashen (gray), or cyanotic (blue) coloration.
    d. Check mucous membranes to be accurate.
  • Observe for increased or decreased areas of pigmentation.
  • Observe for various skin discolorations: ecchymosis, petechiae, purpura, or erythema.

B. Evaluate skin temperature.

  • Palpate skin (especially areas of concern) for temperature.
  • Note changes in different extremities.

C. Assess turgor.

  • Observe skin for its ease of movement and speed of return to original position.
  • Observe for excessive dryness, moisture, wrinkling, flaking, and general texture.
  • Observe for a lasting impression or dent after pressing against and removing finger from skin—indicates edema or fluid in the tissue.

D. Assess skin sensation.

  • Observe the client’s ability to detect heat, cold, gentle touch, and pressure.
  • Note complaints of itching, tingling, cramps, or numbness.

E. Assess signs of poor nutrition.

  • Rough, dry, scaly skin
  • Pigmented or irritated.
  • Bruises or petechiae.

F. Observe cleanliness.

  • Observe general state of hygiene. Note amount of oil, moisture, and dirt on the skin surface.
  • Note presence of strong body odors.
  • Investigate hair and scalp for presence of body lice.

G. Assess integrity (intactness of skin).

  • Note intactness of skin. Observe for areas of broken skin (lesions) or ulcers.
  • Assess any lesion for its location, size, shape, color(s), consistency, discomfort, odor, and sensation associated with it.

H. Assess for presence of skin lesions.

Skin Lesions
A. Macule: a flat, circumscribed, discolored lesion less than 1 cm in diameter.
B. Papule: a raised, solid lesion less than 1 cm in diameter.
C. Nodule: similar to a papule except greater depth.
D. Vesicle: an elevated lesion of skin or mucous membrane filled with fluid.
E. Pustule: a pus-filled vesicle.
F. Wheal: an irregularly shaped and elevated lesion of skin or mucous membrane due to edema; diameter variable.
G. Plaque: a collection of papules.
H. Erosion: a moist depressed area due to partial or full loss of epidermis.
I. Ulcer: the complete loss of dermis leaving irregular depression; scars on healing.

System Implementation
A. Monitor client’s most vulnerable body areas for ischemia, hyperemia, or broken areas.
B. Encourage a well-balanced diet, especially proteinrich foods.
C. Promote high fluid intake to maintain hydration status and prevent skin breakdown.
D. Change the client’s body position at least every 2 hours to rotate weight-bearing areas and prevent pressure ulcers.

  • Observe all vulnerable areas at this time.
  • Include right and left lateral, prone, supine, and swimming-type positioning if possible.

E. Massage skin to increase circulation.
F. Keep skin clean.
G. Protect healthy skin from drainage and environmental pollutants.
H. Encourage active exercise or range of motion to promote circulation.
I. Monitor medications for various skin conditions or lesions.
J. Instruct clients about appropriate skin care.

Medical–Surgical Nursing: Common Skin Lesions

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Cellulitis

Focus topic: Medical–Surgical Nursing

Definition: Infection of the dermis or subcutaneous tissue caused by either streptococcal or staphylococcal organisms— may follow surgical wound, impetigo, trauma, or otitis media.

Assessment
A. Swelling, erythema.
B. Leukocytosis.
C. Pain and itching.

Implementation
A. Monitor systemic antibiotics—effective for the condition.
B. Elevate the extremity to reduce dependent edema.
C. Apply heat to extremity to promote blood circulation.
D. Encourage rest to decrease muscular contractions to limit extension of organism into circulatory system.

Medical–Surgical Nursing: Impetigo

Focus topic: Medical–Surgical Nursing

Definition: A bacterial disease caused by Streptococcus, Staphylococcus, or both.

Characteristics
A. Lesions are intraepidermal vesicles.
B. Lesions progress to pustules, which become crusted.

Implementation
A. Instruct client that the most important intervention is the prevention of the spread of the disease.

  • Complete cleansing with hexachlorophene soap and other hygienic care materials.
  • Separate towels.

B. Instruct that lesions dry by exposure to air; use compresses of Burow’s solution to remove the crusts to allow faster healing.

C. Apply antibiotic ointments.

  • Bacitracin or Bactroban (mupirocin).
  • If no response to topical antibiotic cream, systemic drug (erythromycin) is used.

Medical–Surgical Nursing: Herpes Simplex

Focus topic: Medical–Surgical Nursing

Definition: A viral disease (cold sore) caused by herpes virus, hominis types 1 and 2.

Characteristics
A. Herpes 1.

  • Most common type.
  • Causes burning, tingling, and itching; soon followed by tiny vesicles.
  • Most frequently occurs on lips, but can occur on the face and around the mouth.

B. Herpes 2.

  • Most often the cause of genital infection.
  • Transmitted primarily through sexual contact.
  • Difficult to treat and to prevent recurrence.

Implementation
A. Herpes simplex virus, type 1.

  • Keep area dry; apply drying agent (ether).
  • l-Lysine amino acid: 1 g/day for 6 months.

B. Herpes genitalis, type 2.

  • Avoid sexual contact with active lesion.
  • Use Zovirax (acylovir) cream; recurrence—give Zovirax 200 mg PO × 5 for 5 days.

Medical–Surgical Nursing: Herpes Zoster (Shingles)

Focus topic: Medical–Surgical Nursing

Definition: Acute invasion of the peripheral nervous system due to reactivation of Varicella zoster virus.

Assessment
A. Evaluate eruption with fever, malaise, and pain.
B. Assess vesicles (exudate contains virus) that appear in 3–4 days.
C. Assess client’s status—if immunosuppressed, condition can be life-threatening.

Implementation
A. Isolate client.
B. Apply lotions—calamine, cayenne pepper cream.
C. Administer drugs: analgesics for pain; antiviral agents (Zovirax) and anti-inflammatory drugs such as NSAIDs.
D. Instruct client on preventive measures to enhance immune system.

Medical–Surgical Nursing: Syphilis

Focus topic: Medical–Surgical Nursing

Definition: A communicable sexually-transmitted disease that leads to many structural and cutaneous lesions. Caused by the spirochete Treponema pallidum. The disease is transmitted by direct, intimate contact, or in utero.

Characteristics
A. Transmitted commonly by sexual intercourse, but infants may become infected during birth process. Early-stage syphilis up 29% from 2000, largely among gay men.
B. No age or race is immune to the disease.
C. Diagnosed by serum studies and/or darkfield examination of secretions of the chancre.

  • Wassermann test.
  • Kahn test.

D. No immunity develops, and reinfection is common.
E. Types of syphilis.

  • Early syphilis—two stages.
    a. Primary stage.
    (1) Incubation period is 10 days to 3 weeks.
    (2) Characteristic lesion is red, eroded, indurated papule; the sore or ulcer at the site of the invasion by the spirochete is called a chancre.
    (3) Accompanied by enlarged lymph node in drainage area of chancre.
    (4) May be painless or painful.
    (5) This stage is highly infectious.
    b. Secondary stage.
    (1) Develops if the individual is not treated in the primary stage. Occurs in 2–6 months and may last 2 years.
    (2) May be mild enough to pass unnoticed or may be severe, with a generalized rash on skin and mucous membrane.
    (3) Headache, fever, sore throat, and general malaise are common.
    (4) Disappears by itself if untreated in 3–12 weeks.
  • Late syphilis—tertiary stage.
    a. Symptoms may develop soon after secondary stage or lie hidden for years.
    b. Blood test may be negative.
    c. Less contagious but very dangerous to individual.
    d. If untreated, cardiovascular problems may ensue.
    e. Blindness or deep ulcers may occur.
    f. May be treated with antibiotics but cure is more difficult.

Implementation
A. Advise client that strict personal hygiene is an absolute requirement.
B. Educate client in prevention: symptoms, mode of transmission, and treatment.

C. Assist in case finding; encourage use of clinics for diagnosis and treatment.
D. Administer long-acting penicillin G benzathine (still primary treatment in the early stages).
E. Instruct client to avoid sexual contact until clearance is given by physician.

Medical–Surgical Nursing: Allergic Responses

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Eczema (Atopic Dermatitis)

Focus topic: Medical–Surgical Nursing

Definition: A superficial inflammatory process involving primarily the epidermis.

Characteristics
A. Eczema is a chronic condition with remissions and exacerbations.
B. Eczema occurs at all ages and is common in infancy, especially in those with hereditary allergic tendencies.
C. Treatment is dependent on cause (foods, emotional problems, familial tendencies).
D. Child is isolated from recently vaccinated children; child is not vaccinated.

Assessment
A. Assess for eruptions that are erythematous, papular, or papulovesicular.

  • May be edematous, weeping, eroded, crusted, and/or dry.
  • Chronic form may cause skin to be thickened, scaling, and fissured.

B. Assess if regional lymph nodes are swollen.
C. Assess if irritability is present.

Implementation
A. There is no cure—goals are to reduce pruritus and inflammation and to hydrate and lubricate the skin.

  • Have clients keep fingernails short; provide gloves to prevent scratching.
  • Apply wet dressings soaked in aluminum acetate or tepid therapeutic baths (no soap during acute stages; if client shivers stop bath as body is trying to produce heat to keep warm).
  • Apply mild lotion (calamine) when no oozing or vesiculation is present.
  • Use cornstarch paste to remove crusts.

B. Apply corticosteroids 1% to 2½% (Flonase [fluticasone propionate]) as anti-inflammatory agent.
C. Oral corticosteroids may be given for acute reaction.
D. Topical treatment of zinc spray shows excellent results.

Medical–Surgical Nursing: Contact Dermatitis

Focus topic: Medical–Surgical Nursing

Definition: A skin reaction caused by contact with an agent to which the skin is sensitive.

Characteristics
A. Causes.

  • Clothing (especially woolens).
  • Cosmetics.
  • Household products (especially detergents).
  • Industrial substances (e.g., paints, dyes, cements).

B. Treatment.

  • Avoidance of irritant or removal of irritating clothing.
  • Avoidance of contact with detergent (use of rubber gloves for household chores).
  • Avoidance of contact with industrial agent (use of protective clothing or, for highly sensitive individuals, change of job locations).

Medical–Surgical Nursing: Skin Conditions

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Malignant Skin Tumors

Focus topic: Medical–Surgical Nursing

Assessment
A. Evaluate lesion that starts as a papule and spreads; central area may become depressed and ulcerated.
B. Assess extent of local invasion or extensive local destruction.
C. Evaluate lesions that enlarge rapidly (may indicate basal cell epithelioma, and can metastasize).
D. Assess for any nodular tumor that appears, usually on the lower lip, tongue, head, or neck.

E. Assess for specific type of skin tumor.

  • Basal cell epithelioma is a tumor arising from the basal layer of the epidermis formed because of basal cell keratinization. The typical lesion is a small, smooth papule with telangiectasis and atrophic center.
  • Melanoma is the most malignant of all cutaneous lesions. It arises from melanocytes and is often fatal. It occurs most frequently in light-skinned people when they are exposed to sunlight.
  • Squamous cell carcinoma is a tumor of the epidermis that frequently comes from keratosis and is considered an invasive cancer. The lesion begins as erythematous macules or plaques with indistinct margins, and the surface often becomes crusted.

Implementation
A. Assist with surgical excision, the most effective treatment.

B. Administer cancer drugs if ordered.
C. Assist with irradiation if ordered.

  • Counsel client on side effects of treatment.
  • Offer emotional support throughout treatment.

D. Advise client to prevent occurrence of skin cancer by using sunscreening devices.
E. Advise client to avoid prolonged exposure to sun.
F. Educate client to observe any changes in color or form of moles.
G. Watch for potential malignancy in other locations.

Medical–Surgical Nursing: Lupus Erythematosus

Focus topic: Medical–Surgical Nursing

Definition: A chronic, multisystem autoimmune disease of the connective tissue that may involve any organ of the body. Etiology unknown.

Characteristics
A. Affects women nine times more than men.
B. May affect every cell in the body.
C. Prognosis poor when cardiac, pulmonary, or renal involvement early in disease.

Assessment
A. Onset may be insidious or acute.
B. Assess for discoid eruption—a chronic, localized, scaling erythematous skin eruption over the nose, cheeks, and forehead, giving a characteristic “butterfly” appearance.
C. Evaluate for fever, malaise, and weight loss.
D. Observe for exacerbation and remission of symptoms.
E. Assess for sensitivity to sunlight.
F. Systemic (disseminated) lupus erythematosus may have multiple organ involvement that can lead to death.

  • Pericarditis is common manifestation (30%); myocarditis also present (25% of clients).
  • Lung and pleural involvement common (40% to 50%).
  • Vascular system often involved with inflammation, producing lesions on fingertips, elbows, toes, etc.
  • Lymphadenopathy occurs in half of all clients.
  • Neuropsychiatric symptoms are often present and require intervention.

Implementation
A. Goal of treatment is to prevent loss of organ function— involves careful monitoring.
B. Administer corticosteroid treatment to prevent progression of the disease—most important class of drugs used for treatment.
C. Instruct client to avoid sunlight and local antibiotic ointments that spread the lesions.
D. Apply topical sunscreen preparations.
E. Advise client of possible side effects of prescribed medications; advise client to notify physician promptly if side effects occur so drugs may be discontinued before serious complications.
F. Counsel client to avoid fatigue.
G. Cover up disfigurement from scarring with opaque or tinted cosmetics as recommended by physician.

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