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					                                                                  CHAPTER 50
                                                                 Skin Disorders

LEARNING OBJECTIVES
              KEY TERMS DEFINED
              DISCUSS ASSESSMENT OF THE INTEGUMENTARY SYSTEM
              DISCUSS COMMON DISORDERS OF INTEGUMENTARY SYSTEM—ESPECIALLY BURNS, INFECTIONS, NEOPLASMS,
               AND INFLAMMATORY SKIN DISORDERS
              DISCUSS THE PATHOPHYSIOLOGY OF EACH SKIN DISORDER
              DISCUSS TREATMENT FOR SKIN DISORDERS
              ASSESS THE NURSING CARE NEEDS OF CLIENTS WITH DISORDERS OF THE INTEGUMENT
              PLAN AND IMPLEMENT EFFECTIVE NURSING CARE
*******REVIEW A AND P OF INTEGUMENTARY SYSTEM*****
"THE HEALTH OF THE BODY IS REFLECTED BY THE HEALTH OF THE INTEGUMENTARY SYSTEM"
SKIN, HAIR, NAIL, MUCOUS MEMBRANES—AFFECTED BY INTERNAL AND EXTERNAL CONDITIONS PROVIDED BY AGE, THE SUN,
DRUGS, SYSTEMIC DISEASES.
OUTWARD APPEARANCE OF INTEG. IMPORTANT PSYCHOLOGICALLY AND ESSENTIAL FOR PHYSIOLOGIC WELL-BEING.
NURSING CARE DIRECTED ON THE INTEGUMENT IS FOCUSED ON EITHER MAINTAINING ITS INTEGRITY, OR RESTORING IT TO AN
INTACT STATE.
SKIN ASSESSMENT PARAMETERS--a review
INTEGRITY
BROKEN SKIN
COLOR—PALLOR—PALE SKIN, ESP. FACE. IN DARK-SKINNED PEOPLE LOOK ESPECIALLY AT THE CONJUNCTIVA, NAIL BEDS,
          ORAL MUCOUS MEMBRANES
                     CYANOSIS—BLUISH DISCOLORATION NOTICED IN LIPS, EARLOBES, AND NAIL BEDS
                     JAUNDICE—YELLOWING OF THE SKIN, MUCOUS MEMBRANES AND SCLERA
                     ERYTHEMA—REDDISH HUE TO THE SKIN AS IN SUNBURN AND INFLAMMATION
TEMPERATURE/MOISTURE—COOL, COLD, MOIST, CLAMMY, OR WARMER THAN NORMAL
TEXTURE—LOOSE, WRINKLED, ROUGH, THICKENED, THIN, OILY, FLAKING, SCALING
TURGOR AND MOBILITY—TAUT WITH EDEMA; SLACK WITH DEHYDRATION, RIGID IN SOME DISEASES AS SCLERODERMA
SENSATION—NUMBNESS, TINGLING, INSENSITIVE TO PRESSURE AND SHARP OBJECTS
VASCULARITY-- TELANGIECTASIA—DILATION OF GROUPS OF SUPERFICIAL CAPILLARIES AND VENULES, PETECHIAE—
          PINPOINT HEMORRHAGIC SPOTS, ECCHYMOSIS—LARGE, IRREGULAR HEMORRHAGIC AREAS
HAIR: SMOOTH, SHINY, AND RESILIENT—EXCESS LOSS RESULTS FROM DRUGS, RADIATION, CHEMOTHERAPY, DIETARY,
HORMONAL FACTORS, STRESS, HIGH FEVER.
NAILS: PINK, SMOOTH, SHINY, FIRM YET FLEXIBLE WHEN PALPATED. ANGLE BETWEEN NAIL BODY AND THE EPONYCHIUM OF
160 DEGREES.
MUCOUS MEMBRANES: PINK AND MOIST
DIAGNOSTIC EXAMS :
     KOH—"WET PREP" TO DIAGNOSE FUNGAL INFECTIONS
     SMEAR
     SCRAPING—TO LOOK FOR MITES, THEIR EGGS OR FECES
     BLACK LIGHT EXAM OF THE SKIN
     "PATCH TESTING"—ALLERGIES
     BIOPSY
         SHAVE BIOPSY
         PUNCH BIOPSY
         SURGICAL EXCISION
                     COMMON DISORDERS OF THE SKIN
PRUITUS—Not a disease, but a symptom common to many skin disorders
          psoriasis, dermatitis, exzema, insect bites
some systemic diseases
          urticaria, some cancers, renal failure, DM, thyroid disorders, liver disease, and anemia
Patient Teaching
              CORRECT THE CAUSE—where known
              Avoid things that aggravate itching like temperature extremes, esp. heat, very dry air, irritating fabrics, chemicals,
               frequent hot baths, sweating, stress
              To prevent itching—avoid extreme temps, humidify room air, take less frequent and cooler baths, apply emollients,
               avoid irritating fabrics and chemicals, and practice stress management.
              Use therapeutic measures as prescribed:
                     Topical agents: lotions, creams
                     Systemic agents: antihistamines—dosages, side effects
                     Treatment of underlying condition
                     INFLAMMATORY SKIN DISORDERS
THERE ARE MANY INFLAMMATORY SKIN DISORDERS THAT WE COULD DISCUSS—PROB. FOR WEEKS –
                                           ATOPIC—Main Entry: at·o·py
                     Pronunciation: 'a-t&-pE
                     Function: noun
                     Etymology: Greek atopia uncommonness, from atopos out of the way, uncommon, from a- + topos place
                     Date: 1923
                     : a prob. hereditary allergy characterized by symptoms (as asthma, hay fever, or hives) produced upon exposure to the exciting
                     antigen without inoculation
                     - atop·ic /(")A-'tä-pik, -'tO-/ adjective

Atopic Dermatitis (Eczema)—3 stages
         1. red, oozing, crusty rash and intense pruritis(acute)
         2. redness, excoriations, scaling plaques or pustules, Fine scales give the skin a "silvery" appearance.
         3. dry, thickened, scaly, brownish-gray (chronic)

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ETIOLOGY AND RISK FACTORS
         FAMILY HX OF ASTHMA, HAY FEVER, ECZEMA, FOOD ALLERGIES
 IT IS AN IMMUNE DISORDER—BY WHICH CAME FIRST?
ASSESSMENT CRITERIA-----
SEBORRHEIC DERMATITIS—A CHRONIC INFLAMMATORY DISEASE OF THE SKIN
            SCALP—CALLED DANDRUFF
            EYEBROWS
            EYELIDS
            LIPS
            EARS
            STERNAL AREA
            AXILLAE
            UMBILICUS
            GROIN
            GLUTEAL CREASE
            AREA UNDER THE BREASTS

SX: FINE, POWDERY SCALES, THICK CRUSTS, OR OILY PATCHES
         SCALES MAY BE WHITE, YELLOWISH, OR REDDISH
         PRURITUS
TX: TOPICAL KETOCONAZOLE, TOPICAL CORTICOSTEROIDS,
FOR SCALP: SHAMPOOS MADE OF SELENIUM SULFIDE (SELSUN), TAR, ZINC PYRITHIONATE, OR RESORCIN, AND
CORTICOSTERIOD SOLNS.
ASSESSMENT:
NURSING DIAGNOSES: KNOWLEDGE DEFICIT RELATED TO ____________ AND ITS TX.
INFECTION,RISK FOR RT?
BODY IMAGE DISTURBANCE RELATED TO SCALY LESIONS
SELF ESTEEM DISTURBANCE RELATED TO APPEARANCE
SOCIAL ISOLATION RELATED TO EMBARRASSMENT ABOUT SKIN LESIONS
PSORIASIS—CHRONIC, INFLAMMATORY, NONINFECTIOUS DISEASE OF THE SKIN—ESP. YOUNG ADULTS—NOT CURABLE—CAN
CONTROL SYMPTOMS ONLY--KERATINIZATION GONE AWRY—INSTEAD OF SKIN CELLS PRODUCING A NATURAL BARRIER,
ABNORMAL KERATINIZATION CAUSES LARGE RED PATCHES COVERED WITH THICK SILVERY SCALES WHICH BLEED IF
SCRAPED OFF. IF FINGERNAILS ARE AFFECTED, PITTING AND YELLOW DISCOLORATION WILL OCCUR.
CAUSE UNKNOWN—PROB. GENETIC COMPONENT, EMOTIONAL STRESS, INFECTIONS, TRAUMA, SEASONAL AND HORMONAL
CHANGES CAUSE EXACERBATIONS.
TREATMENT—TO REDUCE INFLAMMATION AND TO SLOW DOWN RATE OF CELL FORMATION—FOR A LIFETIME
KERATOLYTIC AGENTS (CAPABLE OF DISSOLVING KERATIN)—SALICYLIC ACID PREPARATIONS AND COAL TAR PREPARATIONS
PHOTOTHERAPY—ULTRAVIOLET LIGHT AND METHOTREXATE—PROMOTES SHEDDING OF THE EPIDERMIS
PHOTOCHEMOTHERAPY—OXSORALEN, GIVEN 2 HRS. BEFORE LIGHT THERAPY, IS A PHOTOSENSITIZING AGENT THAT REACTS
WITH UV-A LIGHT WAVES TO REDUCE DNA SYNTHESIS (PT INSTRUCTIONS: WEAR DARK GLASSES, SUNSCREEN AND
PROTECTIVE CLOTHING 8 HRS BEFORE AND 8 HRS AFTER TREATMENT)
AND OTHERS
LARGE SIDE EFFECTS—SOMETIMES WILL CAUSE BIRTH DEFECTS.
NURSING DIAGNOSES: KNOWLEDGE DEFICIT RELATED TO PSORAISIS AND ITS TX.
INFECTION,RISK FOR
BODY IMAGE DISTURBANCE RELATED TO SCALY LESIONS
SELF ESTEEM DISTURBANCE RELATED TO APPEARANCE
SOCIAL ISOLATION RELATED TO EMBARRASSMENT ABOUT SKIN LESIONS
INTERTRIGO—INFLAMMATION OF THE SKIN WHERE TWO SKIN SURFACES TOUCH: AXILLA, ABDOMINAL SKINFOLDS, AND AREA
UNDER THE BREASTS—RED, WEEPING WITH CLEAR MARGINS. AREA MAY BE SURROUNDED BY VESICLES AND PUSTULES
ETIOLOGY—HEAT, FRICTION, AND MOISTURE BETWEEN TWO TOUCHING BODY SURFACES.
RISK FACTORS: PRODUCTION OF PERFECT ENVIRONMENT FOR GROWTH OF CANDIDA ALBICANS (YEAST) OR BACTERIA
ASSESSMENT: DAILY INSPECT ALL PLACES WHERE SKIN TOUCHES SKIN
INTERVENTION: WASH 2X DAILY, PAT DRY—CAN USE TALC OR CELLULOSE POWDER, NOT CORNSTARCH BECAUSE IT
SUPPORTS CANDIDA. APPLY TOPICAL MEDICATIONS—ANTIFUNGALS, CORTICOSTEROIDS AS ORDERED.
INFECTIOUS CONDITIONS OF THE SKIN
RISK FACTORS
   ACCESSIBLE PORTAL OF ENTRY
   DECREASED HOST RESISTANCE
   VIRULENT ORGANISMS
         BACTERIA—STAPH. AUREUS—IMPETIGO CONTAG.
                                  STAPH AUREUS--CARBUNCLE
         VIRUSES—VERICELLA-ZOSTER—HERPES ZOSTER (SHINGLES)
                                 HERPES SIMPLEX VIRUS—TYPE 1 & 2
                                 HUMAN PAPILLOMA VIRUS--WARTS
         FUNGAL INFECTIONS
TINEA—CIRCULAR LESIONS SOMETIMES CALLED— RINGWORM
         --CAPITIS-SCALP
         --CORPORIS-BODY
         --CRUCIS-"JOCK ITCH"
         --PEDIS-"ATHLETE'S FOOT"
         --BARBAE—BEARD
         AND CANDIDIASIS—CAN INFECT SKIN, MOUTH, VAGINA, GI TRACT LUNGS
SPREAD BY SHARING CONTAMINATED ARTICLES OR BY DIRECT CONTACT—SCALY PATCHES WITH RAISED BORDERS WITH
PRURITUS

C.albicans (YEAST INFECTION)—PREGNANT, MALNOURISHED, IMMUNOSUPPRESSED, TAKING ANTIBIOTICS, OR ORAL
CONTRACEPTIVES, DIABETICS—COMMON SITES—MOUTH, VAGINA, SKIN AND SKIN AROUND OSTOMY SITE
MUCOUS MEMBRANES INFECTION—RED WITH WHITE PLAQUES—THAT CAN BE SCRAPED OFF
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SKIN INFECTIONS—MOIST RED LESIONS—OFTEN IN FOLDS OF BODY TISSUE
TX: ANTIFUNGALS
ASSESSMENT: CONDITIONS FAVORABLE TO FUNGAL INFECTION---
           ACNE : THIS IS FROM THE "SKIN SITE"
I. Definition:
Acne is the term for pimples and complexion problems which occur in young people and some adults. Pimples usually occur on the face, but may
involve the neck, chest, back and upper arms. Acne is only a skin problem and does not affect your general health.
II. Causes:
          At puberty, the oil glands of the skin start producing an oily material called sebum. Sebum lubricates the skin. Sometimes the wall of the
           oil gland breaks and spills the sebum within the skin which causes redness, swelling, and pus - in other words a pimple. Plugged oil glands
           may form blackheads and whiteheads. Blackheads are not caused by dirt.
          There is a bacteria that normally lives on the skin called Propionibacterium acnes. This bacteria lives on the sebum produced by the skin oil
           glands. Sometimes, this bacteria multiplies and causes inflammation and acne.
          Acne is built into your genes; it runs in families.
          In women, acne frequently worsens at the time of menstruation.
      Foods do not cause acne. In some people, certain foods will make acne worse. The most common ones are chocolate, nuts, carbonated beverages,
      and milk. Most people's acne is not aggravated by these foods.
          Acne may become worse under stress.
          Cosmetics make acne worse.
          Adult women often have trouble with acne through middle age. The reason is unknown.

III. Treatment:
          Dirt does not cause acne. You need to wash your face twice a day with a mild non-soap cleanser.
          Do not pick or squeeze your pimples, as it can leave scars. Acne surgery can be done using sterile instruments to remove blackheads,
           whiteheads, and pimples.
          There is no medical cure for acne. Acne can be controlled, but not cured. Many people do outgrow acne.
          Sunlight may help some acne patients, but is not recommended. Sunlight causes aging, wrinkling of the skin, and skin cancer.
          If cosmetics are used, they should be oil-free (the kind that separates into two layers). Cosmetics labeled water-based may still contain oil.
          If a moisturizer is used, it should be labeled non-comedogenic which means does not cause pimples.

       HERPES SIMPLEX VIRUS (HSV)—TYPE 1 & 2
MOST OFTEN: NOSE, LIPS, (OFTEN CALLED COLD SORES OR FEVER BLISTERS) CHEEKS, EARS, GENITALIA
VIRUSES—VERICELLA-ZOSTER—THE AGENT OF CHICKENPOX, WHICH LIES LATENT IN NERVE TISSUE UNTIL IT IS ACTIVATED IN
THE FORM OF —HERPES ZOSTER (SHINGLES)

               CONTACT DERMATITIS—SKIN REACTS TO EXTERNAL IRRITANTS AS
                          1. ALLERGENS—POISON IVY OR COSMETICS
                          2. HARSH CHEMICALS—DETERGENTS,INSECTICIDES
                          3. METALS—NICKEL
                          4. MECHANICAL IRRITATION—WOOL, GLASS FIBERS
                          5. BODY SUBSTANCES—URINE, FECES
                          SX: PRURITUS, BURNING, ERYTHEMA, MACULOPAPULAR RASH OR COMBINATION PAPULES AND
                                VESICLES (SCRATCHING SPREADS THE DERMATITIS AND 2ND INFECTION.
TX: OUTPT. PATCH TESTING? AVOID ALLERGEN. TOPICAL STEROIDS OR BUROW'S SOLN (1:40 DILUTION ALUMINUM ACETATE.)
 ALUMINUM ACETATE Burow's Solution, Domeboro ®
Tablet: (One Tablet/Pint = 1:40) ($45)
Packets: (One packet/Pint = 1:40) CAL 12s or 100s only ($45)
FERRIC SUBSULFATE Monsel Solution
Solution: 480 mL ($17)
WITCH HAZEL Tucks ®
Pad: 40/Container
    EXFOLIATIVE DERMATITIS—(CAUSE UNKNOWN) INFLAMMATION OF THE SKIN THAT GRADUALLY WORSENS TO INCLUDE:
           SEVERE PRURITUS
           EXTENSIVE SCALING
           ***LOSS OF SKIN SURFACE***
                    DIFFICULT TO MAINTAIN BODY TEMP.
                    *LOSS OF BODY FLUIDS + ELECTROLYTES                            *INFECTION
                    *CAN BE FATAL
MEDICAL CARE: FLUID BALANCE WITH IVS, PREVENT INFECTIONS, DECREASE INFLAMMATION WITH STEROIDS, PROMOTE
COMFORT WITH MEDICATED BATHS, TOPICAL STEROIDS, AND MILD ANALGESICS.
NURSING CARE: PROMOTE HEALING, COMFORT, PREVENT INFECTIONS, FOSTER POSITIVE ATTITUDE.
NURSING DIAGNOSES: SKIN INTEGRITY IMPAIRED, INFECTION, RISK FOR, PAIN, BODY IMAGE DISTURBANCE
BURNS:
CLASSIFIED ACCORDING TO DEPTH AND EXTENT OF SKIN SURFACE INVOLVED.
FIRST AND SECOND DEGREE BURNS—PARTIAL-THICKNESS BURNS
FIRST DEGREE (EPIDERMIS)—SUN BURN—SKIN IS HOT, RED, PAINFUL—HEAL IN 1 WK. WITHOUT SCARRING.
SECOND DEGREE (EPIDERMIS, DERMIS)—IE. SCALDING WATER POURED ON THE SKIN—SKIN HOT, RED, PAINFUL, BLISTERING.
         TISSUE AROUND BURN IS EDEMATOUS WITH EXCESS FLUID—HEAL IN 2 WEEKS WITHOUT SCARRING—OR IF DEEP IN
         DERMIS—MONTHS WITH SCARRING.
THIRD AND FOURTH DEGREE BURNS—FULL-THICKNESS BURNS—WHITE, TAN, BROWN, BLACK, CHARRED OR BRIGHT RED IN
         COLOR—NOT PAINFUL DUE TO DESTRUCTION OF SENSORY NERVE ENDINGS. BODY MOVEMENTS WILL CAUSE PAIN IN
         AREAS OF 1ST AND 2ND DEGREE BURNS.
THIRD DEGREE—ALL DERMAL STRUCTURES DESTROYED AND CAN'T BE REGENERATED. SUBCUTANEOUS TISSUE DAMAGED
FOURTH DEGREE—DAMAGE EXTENDS TO UNDERLYING MUSCLES AND BONES
SKIN CAN REGENERATE ONLY FROM THE EDGES OF FULL-THICKNESS BURNS- GRAFTING MUST BE USED TO PROMOTE
         HEALING--SCARRING IS INEVITABLE
RULE OF NINES—ESTIMATES ADULT BODY SURFACE BURNED—ADDS UP TO 100%--P.1017
PROGNOSIS—DEPENDS ON

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           SEVERITY OF BURN
           SURFACE AREA BURNED
           PREINJURY HEALTH STATUS
COMPLICATIONS:
            RESPIRATORY FAILURE
                 HEAT AND SMOKE. AIRWAY INFLAMMATION AND EDEMA OF RESP. MUCOSACO ATTACHED TO
HEMOGLOBINCARBOXYHEMOGLOBIN WHICH DOES NOT CARRY O2 TO TISSUESCEREBRAL ANOXIA.
IMMEDIATE CARE:
         OPEN AIRWAY + 100% HUMIDIFIED O2 ESSENTIAL
         PERHAPS INTUBATION—DUE TO SWELLING OR BURN DAMAGE
SIGNS THAT THERE MAY BE RESPIRATORY COMPLICATIONS
         FACIAL BURNS
         SINGED NASAL HAIRS
         BLACK-TINGED SPUTUM
            MASSIVE LOSS OF BODY FLUIDS
                 HYPOVOLEMIC AND NEUROGENIC SHOCK—                   FLUID LOST INTO THE BURN WOUND AND
         SURROUNDING TISSUEEDEMACIRCULATORY          COLLAPSE AND RENAL SHUTDOWN.
                         MUST REPLACE FLUIDS AND ELECTROLYTES AS QUICKLY AS THEY ARE LOST
            INFECTIONS—STAPHYLOCOCCUS AUREUS, OR MRSA, OR PSEUDOMONAS AERUGINOSA OR COLIFORM BACILLI
                 REVERSE ISOLATION PRECAUTIONS--?
                 STERILE TECHNIQUE FOR ALL WOUND CARE
                 CARED FOR IN SPECIAL "BURN UNITS"
            TEMPERATURE INSTABILITY
            MONITOR KIDNEY FUNCTION BY USE OF FOLEY CATHETER
            PROPHYLACTIC TETANUS TOXOID
            PAIN—CENTRAL MULTIPORT CATH.—NARCOTICS
            ANXIETY—SURVIVAL, PHYSICAL APPEARANCE, EFFECT ON HIS FAMILY
                                               NURSING CARE PLAN

NURSING DIAGNOSES               GOAL                            NSG. INTERVENTIONS
Gas exchange, impaired          The pt. will have a regular     Mon. vs q 1-2hrs until stable, then q 4 hrs
related to edema and            resp. pattern and O2 sat. of    listen to breath sounds, esp. noting resp. pattern and effort. If on con't
inflammation of the resp.       >90%                            oximetry, note O2 Sat. q vs.
tract                                                           Assess pt's color and LOC
                                                                Doc. assessments and keep MD informed.
                                                                Elevate HOB 30 deg.

NURSING DIAGNOSES             GOAL                         NSG. INTERVENTIONS
Fluid vol deficit, related    The pt. will maintain        Admin. iv at ordered rate.
to increased cap.             electrolytes within normal   Mon. s/s fluid overload:
permeability with loss of     limits and an hourly urine   S.O.B.
large amts of fluid           output >30cc./hr.            crackles in lung bases
through open burn                                          changes in heart rate and/or heart sounds
wounds                                                     change in BP
                                                           increased anxiety
                                                           changes in mental status
                                                           Mon. urine output q hr. Report <30cc/hr
                                                           Record I and O
                                                           Weigh pt qd.
                                                           When tol. oral fluids, set fluid intake goal for each shift—1200cc during day,
                                                           800cc during evening, 500cc during night
                                                           Explain to pt and family reason for high fluid intake
                                                           Involve family in helping pt to achieve the fluid goal
                                                           Keep fluids available, and within dietary restrictions, the pts favorite fluids
                                                           Mon. s/s electrolyte imbalance—inc. muscle weakness, muscle cramps,
                                                           cardiac arrhythmias, fatigue, nausea, dizziness
                                                           Mon. lab. results
STABILIZED CARE
FOCUS OF CARE—PROMOTING HEALING, PREVENTING COMPLICATIONS, CONTROLLING PAIN, RESTORING FUNCTION.
*****PREVENT INFECTIONS*****
LARGE AMOUNT OF DEAD TISSUE WITH FLUIDS AND PROTEINS-—INFECTION CAN BEGIN UNDER THE ESCHAR (A SCAB OF
DENATURED PROTEINS)
BASE OF WOUND MUST BE FREE OF INFECTION AND NECROTIC TISSUE BEFORE IT CAN BE COVERED WITH SKIN GRAFTS
DEBRIDMENT—REMOVING DEAD AND DAMAGED TISSUE OR FOREIGN MATERIAL WITHIN THE BURN
         MECHANICALLY—WITH HYDROTHERAPY
         SURGICALLY
SURGICAL CARE:
              SKIN GRAFTS
                   1. AUTOGRAFT—FROM UNBURNED AREA ON SELF
                   2. HOMOGRAFT—SKIN FROM CADAVER WITHIN 6-24 HRS OF DEATH
                   3. HETEROGRAFT—ANIMAL SKIN SUCH AS PIG
                   4. SYNTHETIC SKIN SUBSTITUTE
TEMPORARY TO STOP WATER, ELECTROLYTE AND PROTEIN LOSS AND FACILITATE HEALING. ALLOW MORE MOVEMENT AND
LESS PAIN---2, 3, 4.
AUTOGRAFT COMPLETED AFTER CONDITION STABLE AND WOUND BEDS HAVE HEALTHY GRANULATION TISSUE—DELICATE
CONNECTIVE TISSUE CONSISTING OF FIBROBLASTS, COLLAGEN, AND CAPILLARIES.
AUTOGRAFTS—SPLIT THICKNESS—EPIDERMIS AND PART OF DERMIS—ALLOWS REGENERATION OF SKIN AT THE DONOR SITE.
         OR
                                 FULL-THICKNESS
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FULL-THICKNESS GRAFT WOULD BE USED TO RESTORE FUNCTION AND COSMETIC APPEARANCE.
SURGERY FOR RECONSTRUCTION OF PERHAPS AN EAR OR EYELID—BLEPHAROPLASTY
                                           NURSING CARE PLAN

    NURSING DIAGNOSES                       GOALS                                          NSG. INTERVENTIONS
Infection, risk for, related to   the Pts burn wounds            Wear clean gloves when giving care
risk factors of tissue            will exhibit signs of          wash hands with an antibacterial skin cleanser before and after gloving
destruction and inadequate        healing without serious        Wear isolation gown over your uniform when giving care
primary defenses                  or life-threatening            When pts wounds are exposed, wear gown, mask, cap and sterile gloves
                                  infections                     Use sterile tech. for wound care and dressing changes
                                                                 Mon. wound daily for signs of infection: redness, swelling, purulent
                                                                 drainage, pain
                                                                 Assess for signs of systemic infections: fever, increased pulse, resp., dec.
                                                                 BP, changes in mentation, confusion, disorientation and delirium
                                                                 Note urinary output
                                                                 Assess for hypoactive Bowel sounds
                                                                 Mon. WBC
                                                                 Assist pt with personal hygiene, and keep noninjured areas of body clean.

    NURSING DIAGNOSES                     GOALS                                            NSG. INTERVENTIONS
Pain related to physical          Pt will verbalize that       Assess for pain q2-4 hrs. by asking pt to rate pain level using a scale of 0-10
injury                            pain is controlled at a      Observe for non- verbal signs of pain as grimacing or crying
                                  tolerable level              Admin. pain med. as ordered, esp. prior to wound care or exercise and
                                                               mobilization activities
                                                               Mon. and doc. response to medications.
                                                               Implement comfort and diversional measures: reposition with pillows for
                                                               good body allignment
                                                               Teach progressive relaxation exercises and guided imagery
                                                               Enc. use of diversional act. as TV. music of his choice.


REHABILITATIVE PHASE—USE OF PRESSURE DRESSINGS TO DECREASE HYPERTROPHIC SCARING—ELASTIC WRAPS,
STOCKINETTES—WORN CONSTANTLY—REMOVED ONLY FOR DAILY HYGIENE CARE—1-2 YEARS FOR BURN SCAR TO MATURE
PHARMACOLOGICAL
IV NARCOTICS—10-15 BEFORE TX (WITH PSYCHOTROPIC DRUGS TO HELP DECREASE ANXIETY AND FEAR, CAN ENHANCE
ANALGESICS, AND HELP COPE WITH PROSPECT OF LONG-TERM REHAB)
TOPICAL AGENTS TO PROMOTE HEALING AND DECREASE INFECTION
SILVER NITRATE USED TO MED OF CHOICE—TURNS EVERYTHING PURPLE, VERY PAINFUL TO APPLY AND FURTHERS THE LOSS
OF NA AND K
DISCUSSION ON P. 1019 OF TEXT PROVIDES A BASIS OF UNDERSTANDING OF PROBLEMS WITH DIF. OINTMENTS
DIET
INCREASED NEEDS OF CALORIES AND PROTEINS
PROTEIN NEEDS INCREASE BY 2-4 TIMES.
CALORIES—2X USUAL
AT FIRST—DUE TO SEVERE BURN—PERISTALSIS IS SLOWED OR STOPPED—ORAL OR TUBE FEEDING CAN'T BE USED UNTIL
PERISTALSIS OCCURS. TPN IS USED, THEN 6-8 SMALL MEALS A DAY WITH ADDITIONAL HIGH PROTEIN MILK SHAKES ADDED TO
HELP MEET NUTRITIONAL NEEDS. (THE NEGATIVE NITROGEN BALANCE DUE TO THE HIGH METAB. OF PROTEIN CAUSES A LACK
OF APPETITE. )
ACTIVITY
CONTRACTURES ARE MOST SERIOUS COMPLICATION
           POSITIONING—MUST BE IN ALIGNMENT
           SPLINTING—TO PREVENT CONTRACTURES, OR IMMOBILIZE JOINTS AFTER GRAFTS
           EXERCISING—ROM TO MAINTAIN JOINT MOBILITY—AROM ASAP TO INCREASE CIRCULATION, MAINTAIN JOINT
                           FLEX., AND IMPROVE MUSCLE TONE
           AMBULATING—AS SOON AS PT. RECOVERS ENOUGH TO BEGIN INCREASING ADLS
                                                NURSING CARE PLAN

    NURSING DIAGNOSES                        GOALS                                            NSG. INTERVENTIONS
Nutrition, altered, less than      The pt will ingest               If on TPN, admin. at ordered rate, and mon. reaction
body requirements, related to      sufficient calories daily        When oral intake ordered, enc. pt to eat 90-100% daily diet
increased caloric                  to meet increased                Provide oral hygiene before and after meals
requirements and difficulty        metabolic needs                  Give 6-8 small meals—enc. family participation When able, have pt sit
ingesting sufficient quantities                                     up and eat in a chair
of food                                                             Plan care so that painful procedures are not done immed. before
                                                                    meals—at least 30 min rest before meals
                                                                    Determine time of day when client feels most like eating and does eat
                                                                    most of the meal, and serve the highest calorie/protein nutrients at that
                                                                    time

    NURSING DIAGNOSES                        GOALS                                             NSG. INTERVENTIONS
Body image disturbance,            Pt will state realistic          Provide time for pt to express feelings (fear, anger, frustration, regret,
related to change in physical      expecta-tions for                and depression are commonly expressed by pts with burns) and
appearance with loss of body       recovery and participate         practice active listening.
tissues or body parts              in rehabilita-tion               Explain healing process to pt.
                                                                    Give pt. daily updates on degree of wound healing and on his rehab.
                                                                    progress
                                                                    Enc. pt. to look at his wounds for evidence of healing and stress that
                                                                    wound healing following serious burns proceeds slowly and may take a
                                                                    year or more for complete healing with improved skin appear. to occur.
e75f9f15-ec29-4487-b0e8-3ca05f4f5f69.doc                    Linton, Maebius Introduction to Medical-Surgical Nursing 2003                      5
                                                NEOPLASMS
MOST COMMON SKIN CANCERS
        1. BASAL CELL CARCINOMA
        2. SQUAMOUS CELL CARCINOMA
        3. MALIGNANT MELANOMA
LEADING CAUSE OF SKIN CANCER
                 SUN EXPOSURE
SKIN DAMAGE FROM SUN IS ACCUMULATIVE
MOST LONG TERM DAMAGE FROM SUN EXPOSURE OCCURS DURING CHILDHOOD PRIOR TO DEVELOPMENT OF THE ABILITY TO
TAN—LATE TEENS
10-20 YRS. AFTER OVER EXPOSURE BEFORE SKIN CANCER DEVELOPES.

1.   BASAL CELL CARCINOMA—FROM EPIDERMIS—MOST COMMON FORM OF SKIN CANCER
           PROLONGED SUN EXPOSURE
           POOR TANNING ABILITY
           PREVIOUS THERAPY WITH X-RAYS FOR FACIAL ACNE
CAN EXTEND INTO THE DERMIS
CAN MAKE AN OPEN ULCER
SURGERY IS CURATIVE
2. SQUAMOUS CELL CARCINOMA—NODULAR LESION IN THE EPIDERMIS—LESS COMMON THAN BASAL CELL
           PROLONGED SUN EXPOSURE
           EXPOSURE TO GAMMA RADIATION
           EXPOSURE TO X-RAY
CAN EXTEND INTO THE DERMIS
CAN METASTASIZE TO OTHER BODY ORGANS
CAN BE FATAL
COMMON SITE –LOWER LIP
TREATMENT:
        SURGERY
        CHEMOTHERAPY
3. MALIGNANT MELANOMA—BOTH EPIDERMIS AND DERMIS—MOST SERIOUS OF THE 3 TYPES OF SKIN CANCERS—NO CURE—
MAY BEGIN IN MOLE—IRREGULAR SHAPE >6MM IN DIAMETER
           METASTASIZE THROUGH BLOOD & LYMPH TO EVERY ORGAN IN THE BODY
           SUN EXPOSURE
                 PEAK INCIDENCE—21-45 YRS.
                 DOUBLING EVERY 10 YRS.
           PREVENT
                    LIMIT SUN EXPOSURE
                    USE SUNSCREEN PROPERLY TO LIMIT DAMAGE FROM UV RAYS
MYCOSIS FUNGOIDES=T-CELL LYMPHOMA
        BOTH SKIN MANIFESTATIONS AND MULTIPLE ORGAN SYSTEM MANIFESTATIONS—LOOKS LIKE PSORIASIS OR
SEBORRHEIC DERMATITISSEVERE PRURITUS, FISSURES AND SKIN ULCERSULTIMATELY FATAL DUE TO INVOLVEMENT OF
VITAL ORGAN SYSTEMS.
NEOPLASMS: NONMALIGNANT
(BENIGN TUMORS OF THE SKIN)
LIPOMAS—BENIGN FATTY TUMORS
SEBACEOUS CYSTS—SEBACEOUS GLANDS FILLED WITH SEBUM
KELOIDS—ABNORMAL GROWTH OF SCAR TISSUE
ANGIOMAS—"BIRTHMARKS"
NEVI--MOLES
                                             NURSING CARE PLANS
NURSING DIAGNOSES:
BODY IMAGE DISTURBANCE
SKIN INTEGRITY, IMPAIRED
PAIN
FEAR
FAMILY PROCESS, ALTERED, RELATED TO THE SHIFT IN HEALTH STATUS OF A FAMILY MEMBER
KNOWLEDGE DEFICIT RELATED TO: RELATIONSHIP BETWEEN SUN EXPOSURE AND SKIN CANCER
OR
          :REGARDING USE OF SUN SCREEN FOR PROTECTION AGAINST FUTURE SKIN CANCER IN THEIR CHILDREN




e75f9f15-ec29-4487-b0e8-3ca05f4f5f69.doc   Linton, Maebius Introduction to Medical-Surgical Nursing 2003   6

				
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