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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 50 Skin Disorders.

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1 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 50 Skin Disorders

2 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Learning Objectives Describe the structure and functions of the skin. List the components of the nursing assessment of the skin. Define terms used to describe the skin and skin lesions. Explain the tests and procedures used to diagnose skin disorders. Explain the nurses responsibilities regarding the tests and procedures for diagnosing skin disorders. Explain the therapeutic benefits and nursing considerations for patients who receive dressings, soaks and wet wraps, phototherapy, and drug therapy for skin problems. Describe the pathophysiology, signs and symptoms, diagnostic tests, and medical treatment for selected skin disorders. Assist in developing a nursing care plan for the patient with a skin disorder.

3 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of the Skin

4 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Definition The skin is an organ that covers the body surface Two distinct layers

5 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Epidermis Outermost layer that covers the dermis Continually produces new cells to replace those at the surface Produce melanin, a dark pigment, that helps determine the color of the skin Strong ultraviolet light, such as in sunlight, stimulates the production of melanin

6 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Dermis Strong connective tissue that contains nerve endings, sweat glands, hair roots Well supplied with blood vessels, causing the skin to redden when surface vessels are dilated Subcutaneous tissue lies beneath the dermis

7 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-1

8 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Appendages Hair, nails, and sebaceous glands Hair root located in tube in dermis called a hair follicle Arrector muscles located around hair follicles contract, causing hairs to stand erect and gooseflesh skin Sebaceous glands secrete oily substance: sebum Sweat glands, in most parts of the skin, secrete through skin surface water that contains salts, ammonia, amino acids, lactic acid, ascorbic acid, uric acid, and urea

9 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Functions Protection Temperature regulation Secretions Sensation Synthesis of vitamin D Blood reservoir

10 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Age-Related Changes Wrinkling a result of thinning skin layers and degeneration of elastin fibers Sweat glands decrease, although production changes little until advanced age Production of sebum decreases, becoming apparent earlier in women than in men Dryness and pruritus are common Skin pales because the number of cells that produce melanin decreases

11 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Age-Related Changes Skin lesions are more common Lentigines Senile purpura Senile angiomas Seborrheic keratoses Acrochordons By age 50, nearly half have some gray hair Men begin to lose hair from the scalp in their 40s; by their 80s many almost bald

12 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Age-Related Changes Scalp hair thins in women as well but usually less obvious Increase in facial hair in both sexes Men may have increased hair in the nares, eyebrows, or helix of the ear Nails flatten; become dry, brittle, and discolored

13 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-2

14 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Chief complaint and history of present illness Discomfort, pruritus, color changes, lesions, hair loss, or abnormal hair growth Onset of condition/precipitating or alleviating factors Past medical history Previously diagnosed skin diseases or problems, current and recent medications, and allergies Diabetes mellitus, cancer, kidney failure, thyroid disease, liver disease, and anemia

15 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Review of systems Change in skin color or pigmentation, change in a mole, sores slow to heal, itching, dryness or scaliness, excessive bruising, rashes, lesions, hair loss, unusual hair growth, changes in nails Functional assessment Past and present occupations, exposure to chemicals or other irritants, skin care habits, sun exposure Recent changes in the work or living environment Current stresses and sources of anxiety

16 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Assessment Skin color and variations in pigmentation Document dilated blood vessels and angiomas Nevi (moles) inspected for irregularities in shape, pigmentation, and ulcerations or changes in surrounding skin If a rash, location, distribution, and characteristics. If any drainage, the color, amount, and odor are noted

17 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-3

18 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Assessment Palpate skin for temperature, moisture, texture, thickness, edema, mobility, and turgor Mobility and turgor Hair color, distribution, oiliness, and texture. The scalp is inspected for scaliness, infestations, and lesions Shape/contour of the fingernails and toenails Color of the nail bed Capillary refill checked by applying pressure to the nail to cause blanching and then releasing

19 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-4

20 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures Microscopic examination of skin specimens Potassium hydroxide (KOH) examination Tzanck smear Scabies scraping Woods light examination Patch testing for allergy Biopsy Shave biopsy Punch biopsy Surgical excision

21 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Therapeutic Measures Dressings Protect wounds; retain surface moisture Types: wet, dry, absorptive, and occlusive Negative pressure wound therapy Reduce healing time of traumatic wounds, dehisced surgical wounds, pressure and chronic ulcers Soaks and wet wraps Soothe, soften, and remove crusts, debris, and necrotic tissue

22 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Therapeutic Measures Phototherapy Ultraviolet light in combination with photosensitive drugs promotes shedding of the epidermis Drug therapy Topical drugs: keratolytics, antipruritics, emollients, lubricants, sunscreens, tars, anti-infectives, glucocorticoids, antimetabolites, antihistamines, antiseborrheic agents, and vitamin A derivatives

23 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Disorders of the Skin

24 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pruritus Etiology and risk factors Triggered by touch, temperature changes, emotional stress, and chemical, mechanical, and electrical stimuli Prominent symptom of psoriasis, dermatitis, eczema, insect bites

25 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pruritus Medical treatment Stress management and avoidance of known irritants, sudden temperature changes, and alcohol, tea, and coffee Lubricants in the bathwater and emollients applied after bathing also may help Medications include corticosteroids, antihistamines, and local anesthetics

26 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pruritus Assessment Collect data about symptoms that may help determine the cause The history of the current illness is important because pruritus may be just one symptom of a condition that requires attention

27 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pruritus Interventions Lubricants/emollients; adding oils to bathwater Advise to avoid bathing in very hot water Administer medications or instruct patient in their use Inspect skin daily to determine effects of treatment Explain possible causes of pruritus and encourage the patient to avoid them

28 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Atopic Dermatitis (Eczema) Pathophysiology Acute stage: red, oozing, crusty rash and intense pruritus Subacute stage: redness, excoriations, and scaling plaques or pustules. Fine scales may give skin a silvery appearance Chronic stage: the skin becomes dry, thickened, scaly, and brownish gray

29 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Atopic Dermatitis (Eczema) Etiology and risk factors Personal or family history of asthma, hay fever, eczema, or food allergies People with atopic dermatitis have an immune dysfunction, but it is not known whether that dysfunction is a cause or an effect of the disorder

30 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-6

31 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Atopic Dermatitis (Eczema) Medical diagnosis Health history and physical examination Skin biopsy, serum immunoglobulin E levels, and cultures; allergy tests Medical treatment Topical corticosteroids; systemic antihistamines

32 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Atopic Dermatitis (Eczema) Assessment Allergies, bathing practices, and current medications Interventions Impaired Skin Integrity Risk for Infection Disturbed Body Image

33 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seborrheic Dermatitis Pathophysiology Chronic inflammatory disease of the skin Affects scalp, eyebrows, eyelids, lips, ears, sternal area, axillae, umbilicus, groin, gluteal crease, and under the breasts Areas affected by this condition may have fine, powdery scales, thick crusts, or oily patches Scales may be white, yellowish, or reddish Pruritus is common

34 34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seborrheic Dermatitis Etiology and risk factors The cause is unknown May be an inflammatory reaction to infection with the yeast Malassezia

35 35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seborrheic Dermatitis Medical diagnosis Health history and physical examination Medical treatment Topical ketoconazole (Nizoral), sometimes with topical corticosteroids Shampoos that contain selenium sulfide (Selsun), ketoconazole, tar, zinc pyrithionate, salicylic acid, or resorcin

36 36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seborrheic Dermatitis Assessment Inspect and describe the affected areas Interventions Explain the condition and reinforce the physicians instructions for treatment

37 37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Psoriasis Pathophysiology Abnormal proliferation of skin cells Classic sign: bright red lesions that may be covered with silvery scales Etiology and risk factors Caused by rapid proliferation of epidermal cells Usually chronic with cycles of exacerbations and remissions

38 38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Psoriasis Medical diagnosis Health history and physical examination Medical treatment No cure; usually treated with topical medications: corticosteroids, tazarotene, Estar (coal tar), and vitamin D derivatives

39 39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-7

40 40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Psoriasis Assessment Describe symptoms and treatments Inspect affected areas for lesions and scales Document joint pain or stiffness because the condition may cause arthritis Interventions Ineffective Therapeutic Regimen Management Disturbed Body Image Social Isolation

41 41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Intertrigo Pathophysiology Inflammation where two skin surfaces touch: axillae, abdominal skinfolds, and under the breasts The affected area is usually red and weeping with clear margins; may be surrounded by vesicles and pustules Etiology and risk factors Results from heat, friction, and moisture between touching surfaces

42 42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Intertrigo Medical diagnosis and treatment Based on site/appearance of inflamed skin If the skin not broken, wash with water twice daily; rinse and pat dry; soft gauze used to separate layer of tissue and absorb moisture For severe inflammation or fungal infection: topical corticosteroid or antifungal agent

43 43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Intertrigo Assessment Complaints of pain, irritation, or redness in body folds Inspect susceptible areas daily

44 44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Intertrigo Interventions Areas where skin surfaces are in contact must be kept clean and dry Apply topical medications as ordered Report increasing redness and tenderness, fever, and broken skin to the physician Encourage women with pendulous breasts to wear a soft, supportive bra If incontinence has contributed to perineal intertrigo, position patient with legs apart to allow moisture to evaporate

45 45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fungal Infections Pathophysiology Tinea pedis (athletes foot) Tinea manus (hand) Tinea cruris (groin) Tinea capitis (scalp) Tinea corporis (body) Tinea barbae (beard) Candidiasis: affects skin, mouth, vagina, gastrointestinal tract, and lungs

46 46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fungal Infections Etiology and risk factors Spread through direct contact or by inanimate objects Lesions may be scaly patches with raised borders Pruritus common symptom Medical diagnosis Confirmed by microscopic examination of skin scrapings Medical treatment Fungal: treated with antifungal powders and creams Oral candidiasis: treated with clotrimazole troches, nystatin mouthwash or lozenges, oral amphotericin B

47 47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-8

48 48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fungal Infections Assessment Conditions that might make a person susceptible to fungal infections Inspect the skin and mucous membranes for lesions Interventions Disturbed Body Image Altered Oral Mucous Membrane Risk for Injury

49 49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acne Pathophysiology Affects the hair follicles and sebaceous glands Comedones (whiteheads, blackheads), pustules, cysts Often develop on the face, neck, and upper trunk Etiology and risk factors Androgenic hormones cause increased sebum production; bacteria proliferate, causing sebaceous follicles to become blocked and inflamed Medical diagnosis Health history and physical examination findings

50 50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acne Medical treatment Topical medications: antibiotics, keratolytics such as benzoyl peroxide, topical vitamin A preparations Oral antibiotics given over several months Nonpharmacologic treatment: comedo extraction or cryotherapy Dermabrasion to reduce scarring

51 51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acne Assessment Document any treatments being used Inspect skin to determine extent and severity Interventions Disturbed Body Image Ineffective Therapeutic Regimen Management

52 52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Herpes Simplex Etiology and risk factors Viral infection begins with itching and burning and progresses to vesicles that rupture and form crusts Nose, lips, cheeks, ears, genitalia most often affected Oral lesions called cold sores or fever blisters Infections on the face and upper body usually caused by HSV- 1; genital infections by HSV-2 Medical diagnosis Laboratory studies of exudate from a lesion and blood studies to detect specific antibodies

53 53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-9

54 54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Herpes Simplex Assessment Describe the development of the herpetic lesions Sexual contacts documented so that they can be advised of the need for medical evaluation Inspect the lesions Interventions Acute Pain Ineffective Coping Ineffective Therapeutic Regimen Management

55 55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Herpes Zoster Etiology and risk factors Commonly called shingles Varicella-zoster virus; also causes chickenpox Symptoms: pain, itching, and heightened sensitivity along a nerve pathway, followed by the formation of vesicles in the area When the skin is affected, crusts form Older adults especially susceptible to complications Immunosuppressed at greater risk for herpes zoster infections; may have serious systemic complications

56 56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-10

57 57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Herpes Zoster Medical diagnosis Health history and physical examination findings Tzanck smear or viral culture of material from a lesion Medical treatment Antiviral agents: acyclovir, famciclovir, valacyclovir, and foscarnet Wet dressings soaked in Burows solution Pain may be treated with analgesics and sedatives

58 58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Herpes Zoster Assessment Conditions or treatments that might cause the patient to have a reduced immune response Distribution and appearance of the lesions Interventions Impaired Skin Integrity Acute Pain Ineffective Coping

59 59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Necrotizing Fasciitis Infection of deep fascial structures under the skin Aerobic and anaerobic organisms: Streptococcus, Staphylococcus, Peptostreptococcus, Bacteroides, and Clostridium species Organisms excrete enzymes that destroy blood vessels that supply the affected area Deprived of blood flow, tissue necrosis occurs Treatment involves extensive débridement, intravenous and topical antibiotics, and eventual skin grafting

60 60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infestations Lice Scabies

61 61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-12

62 62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pemphigus Chronic autoimmune condition: bullae (blisters) develop on the face, back, chest, groin, and umbilicus Blisters rupture easily, releasing a foul-smelling drainage Potassium permanganate baths, Domeboro solution, and oatmeal products soothe the affected areas, reduce odor, and decrease the risk of infection Treatments: corticosteroids, other immunosuppressants, and oral or topical antibiotics Patients with extensive skin loss require the same care as burn patients

63 63Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Actinic Keratosis Precancerous lesions most often found on the face, neck, forearms, and backs of the handsall areas exposed to sunlight May become malignant if not treated Most common among older white adults Appear as papules or plaques of irregular shape The hard scale on the lesion may shed and reappear Treatments include drug therapy, cryotherapy, electrodesiccation, and surgical excision

64 64Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nonmelanoma Skin Cancer Basal cell carcinoma Painless, nodular lesions; pearly appearance Related to sun exposure Grow slowly and rarely metastasize Treated with surgical excision, Mohs micrographic excision, electrodesiccation and curettage, cryotherapy, radiation, or drugs that are applied topically or injected into the lesion

65 65Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nonmelanoma Skin Cancer Squamous cell carcinoma Scaly ulcers or raised lesions Develop on sun-exposed areas including the lips, and in the mouth Caused by overuse of tobacco and alcohol Grow rapidly and metastasize Treatment may include surgical excision, cryotherapy, and radiation therapy

66 66Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-13A-C

67 67Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Melanoma Arises from pigment-producing cells in the skin Most serious form of skin cancer; fatal if it metastasizes Found anywhere on the body Irregular borders and uneven coloration; many are dark, but some are light. Begin as tan macule that enlarges Removed surgically; a wide area around a melanoma is usually excised Chemotherapy and immunotherapy also may be employed

68 68Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-13D

69 69Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cutaneous T-Cell Lymphoma Migration of malignant T cells to the skin Mycosis fungoides and Sézary syndrome May resemble eczema, with macular lesions appearing on areas protected from the sun Tumors form, enlarge, spread to distant sites When confined to the skin, this type of lymphoma can be cured with topical chemotherapy, systemic psoralens with UVA, and/or superficial radiotherapy

70 70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Kaposis Sarcoma Malignancy of the blood vessels Red, blue, purple macules with pain, itching, swelling Lesions appear first on the legs and then on the upper body, face, and mouth Enlarge to form large plaques that may drain In patients with HIV but not confined to this group Local lesions excised or injected with intralesional chemotherapy Systemic lesions are treated with chemotherapy, immune therapy, and radiotherapy

71 71Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Disorders of the Nails

72 72Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infections Usually indicated by redness, swelling, and pain around the margin of the nail Treated with warm soaks and topical or systemic anti-infectives Incision and drainage may be necessary

73 73Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Ingrown Toenail Painful inflammation at distal corner of nail Caused by trimming nail too short at the corners or wearing shoes that are too tight Ingrown nail should be protected from pressure as it grows out Warm soaks may be soothing Surgical excision of ingrown portion of nail

74 74Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient with a Nail Disorder Assessment Health history should document the diagnoses of diabetes mellitus or peripheral vascular disease In the physical examination, inspect the nails for redness, swelling, or pain Inspect extremities for lesions and abnormal color, and palpate for warmth and peripheral pulses

75 75Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient with a Nail Disorder Interventions Teach patients how to trim their nails correctly and the importance of properly fitting shoes Toenails should be cut straight across and even with the end of the toe If patient cannot care for the feet adequately, refer to a podiatrist

76 76Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Burns

77 77Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Definition of Burns Tissue injuries caused by heat Depending on source of injury, burn is described as thermal (flame, flash, scalding liquids, hot objects), chemical, electrical, radiation, or inhalation Leading cause of accidental death despite improved survival rates attributed to advances in the care of burn patients

78 78Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Classification Burn size Rule of nines Lund and Browder method Burn depth Superficial burn (first degree) Affect only the epidermis Superficial or deep partial-thickness burn (second degree) Affects the epidermis and the dermis Full-thickness burns (third degree, fourth degree) Extend into even deeper tissue layers

79 79Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-15

80 80Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-16

81 81Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-17

82 82Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Burn Severity American Burn Association criteria Burn size: 25% or more body surface area for people younger than 40 years; 20% or more body surface area for older than 40 years Disfiguring or disabling injuries to the face, eyes, ears, hands, feet, or perineum High-voltage electrical burn injury Inhalation injury Major trauma in addition to the burn

83 83Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pathophysiology of Burn Injury Local effects Tissue releases chemicals that cause increased capillary permeability, which permits plasma to leak into the tissues Injury to cell membranes permits excess sodium to enter cell and potassium to escape into the extracellular compartment These shifts cause local edema and decrease in cardiac output Fluid evaporates through the wound surface, further contributing to the declining blood volume 18 to 36 hours after a burn injury, capillary permeability begins to normalize and reabsorption of edema fluid begins Cardiac output returns to normal and then increases to meet increased metabolic demands

84 84Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pathophysiology of Burn Injury Systemic effects Fluid balance Gastrointestinal function Immune system Respiratory system Myocardial depression Psychological effects

85 85Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Stages of Burn Injury Emergent: begins with the injury and ends when fluid shifts have stabilized Acute: begins with fluid stabilization and ends when all but 10% of burn wounds are closed or when all wounds are closed Rehabilitation: lasts as long as efforts continue to promote improvement

86 86Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment: Emergent Stage Assess airway, breathing, and circulation and then determine whether the patient has injuries in addition to the burn If inhalation injury, oxygen therapy is started May require intubation if airway is compromised IV lines established to begin fluid resuscitation and to provide emergency vascular access

87 87Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment: Emergent Stage Indwelling urinary catheter and a nasogastric tube usually inserted Blood drawn for baseline lab studies Tetanus prophylaxis may be administered Pain assessed and analgesics are ordered Wound is cleaned, débrided, and inspected

88 88Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment: Emergent Stage Patient with serious burns is transferred to a burn specialty care unit or a critical care unit IV essential during the first few days of burn treatment Volume based on patients weight and extent of injury First 24 hours, IV fluids may consist of various combinations of electrolyte, colloid, and dextrose solutions Second 24 hours, volume decreased based on urine output Fluids then different combinations of electrolyte, colloid, and dextrose solutions Some formulas omit electrolyte solutions in the second 24 hours Antibiotic therapy and surgical procedures

89 89Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Wound Care Open method: topical antimicrobials but no dressings Closed care: topical medications covered by dressings Topical medications: silver sulfadiazine (Silvadene) and mafenide acetate (Sulfamylon) Tetanus booster given if patient has not been immunized within the past 5 years

90 90Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Wound Care For clean partial-thickness wounds that will heal without grafting, temporary wound coverings Amniotic membranes, grafts from cadavers or pigs, and a number of synthetic materials Graft sites also treated with negative pressure wound therapy Donor sites treated with fine-mesh gauze and synthetic and biosynthetic products

91 91Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Wound Care Débridement Removal of debris and necrotic tissue from a wound By scissors, forceps, surgical excision, or enzymes Skin grafting Autograft: the patients own skin Split-thickness or a full-thickness graft Scarring Can be reduced with pressure dressings in the early stages of care, followed by custom-fitted garments that apply continuous pressure

92 92Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 50-18

93 93Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient with Burn Injury Health history Circumstances surrounding the burn injury Chronic diseases, surgeries, or hospitalizations Medications and allergies Family history even though not specific to burn injuries; it may alert the staff to other problems Review of systems detects current problems Habits and lifestyle, roles and responsibilities, stressors, and coping strategies

94 94Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient with Burn Injury Physical examination Vital signs Inspect for burn wounds and other lesions Wound color and the presence of eschar Palpate intact skin for temperature and turgor Chest expansion observed, and the lungs auscultated for wheezing, stridor, or atelectasis Apical pulse be auscultated for rate and rhythm Abdomen assessed: active bowel sounds/distention Extremities are inspected for injury and deformity ROM assessment is delayed if extremity immobilized

95 95Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient with Burn Injury Interventions Decreased Cardiac Output Fluid Volume Excess Acute Pain Risk for Infection Hypothermia Risk for Imbalanced Nutrition: Less Than Body Requirements Impaired Physical Mobility Ineffective Coping Ineffective Family Coping

96 96Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Conditions Treated with Plastic Surgery

97 97Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Aesthetic Surgery Alters a body feature that is structurally normal but perceived by the patient as unattractive Examples: rhytidectomy, blepharoplasty, chin implants, rhinoplasty, abdominoplasty, breast augmentation, and breast reduction

98 98Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Reconstructive Surgery Repair disfiguring scars, restore body contours after radical surgery like mastectomy, eliminate benign lesions such as birthmarks, restore features damaged by trauma or disease, and correct developmental defects

99 99Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Preoperative Nursing Care Assessment: health history Patients description of plastic surgery and what he or she expects the procedure to accomplish. Past medical history may elicit conditions that might affect wound healing Review of systems: surgical area receives special attention Functional assessment: patients lifestyle and usual activities Interventions Anxiety Deficient Knowledge

100 100Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Postoperative Nursing Care Assessment Vital signs and level of consciousness Inspect dressings for drainage or bleeding, but do not remove them without specific orders Observe flaps and grafts for color and evidence of fluid accumulation, and palpate for warmth Inspect and measure drain contents each shift Fluid should lighten from sanguineous (red) to serosanguineous (pink) to serous (pale yellow) Patients comfort level

101 101Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Postoperative Nursing Care Acute Pain Risk for Infection Risk for Injury Risk for Deficient Fluid Volume Disturbed Body Image Ineffective Therapeutic Regimen Management


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