INTEGUMENTARY OBJECTIVES by mikesanye

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									           INTEGUMENTARY
           OBJECTIVES 1-11
   Integumentary system is made up
    of:
   Skin, accessory structures, and
    subcutaneous tissues
   Body covering separating internal
    environment from external
    environment
   Barrier against pathogens, most
    chemical, and injury to inner
    structures.
   Is an organ, the largest
              EPIDERMIS
   Stratified,squamous epithelial tissue
   AVASCULAR; nourishment from
    DERMIS
   Thickest on palms of hands, soles of
    feet
   Innermost layer is STRATUM
    GERMANITIVUM
   Mitosis occurs to produce NEW
    epidermal cells. Usually occurs at
    constant rate, but increased pressure
    produces increased production to
   New cells in the EPIDERMIS produce
    KERATIN
   Keratin is a waterproofing protein,
    prevents loss of water as well as prevents
    entry of excess H2O. When die and slough
    off, also removes pathogens
   As new cells get pushed to surface of
    epidermis, they die, become the STRATUM
    CORNEUM, OUTERMOST LAYER
   Loss of large portions of this layer greatly
    increase risks for infection and
    dehydration
   MELANOCYTES,cells in the lower EPIDERMIS,
    produce the protein MELANIN. Amounts produced
    are genetically determined. Melanin is what gives
    color to skin and hair.
   Exposing melanin to UV rays causes an increase
    in production. Melanin is incorporated in to the
    epidermal cells, making them darker before they
    die. Tanning is a direct result of this process.
   Melanin is important in that it acts as a pigment
    barrier to exposure from UV rays and thereby,
    protects the str. germanitivum from mutational
    changes that can lead to extensive skin damage
    and cancerous lesions.
   Langerhans cells, a type of
    MACROPHAGE, are located in BOTH
    the epidermis and the dermis. They
    act to present ANTIGENS to the
    HELPER T CELLS; a first line barrier
    to invasion through the skin by
    pathogens
                 DERMIS
   Made up of fibrous connective tissue
   Cells are called FIBROBLASTS
   They produce THE PROTEIN FIBERS OF
    COLLAGEN and ELASTIN,which support
    the skin and allow for some skin
    stretching and recoil
   THE DERMIS ALSO CONTAINS the hair
    and nail follicles, GLANDS, NERVE
    ENDINGS AND BLOOD SUPPLY. THE blood
    CAPILLARIES are found in the PAPILLARY
    layer of the dermis
                      HAIR
   Developes in FOLLICLES located in the
    EPIDERMAL structures.
   The hair root is a group of cells that
    undergo mitosis to produce the hair shaft
   Cells die AFTER producing KERATIN and
    incorporating MELANIN
   Eyelashes,eyebrows,keep dust and sweat
    out of eyes. Nostril hair filters air entering
    nasal cavities.Hair on head, not sparse
    body hair, provides for thermal regulation
                  NAILS

   Follicles found at ends of fingers and
    toes
   Growth similar to growth of hair,
    starts in the layer of DERMIS
   Mitosis in nail root, produces new
    cells containing keratin.
   Dead cells form the visible nail
   Protect ends of digits from
    mechanical injury
             RECEPTORS
   SENSORY RECPTORS for the
    cutaneous senses are located in the
    DERMIS.
   FREE nerve endings are receptors for
    heat, cold and pain
   ENCAPSULATED nerve endings are
    for touch and pressure
   Sensitivity is = to # of nerve endings
    present
          Sebaceous glands and
           sudoriferous glands
   Sebaceous gland ducts open into hair
    follicles or directly onto surface of skin
   Sebum (a lipid substance) is secreted
   Inhibits growth of some bacteria and
    drying of skin and hair
   Sudoriferous glands are SWEAT GLANDS
   2 kinds: APOCRINE (modified scent
    glands),and ECCRINE (sweat is secreted
    onto skin surface)
   APOCRINE found in axilla and genital
    areas. Activated by stress and emotions.
   ECCRINE throughout dermis, but
    more numerous on face, palms,
    soles; activated by high
    temperatures or exercise.
   Effective cooling mechanism
   MODIFIED sweat glands or
    CERUMINOUS glands are located in
    the dermis of ear canals
   Prevents drying of outer surfaces of
    ear canal
           BLOOD VESSELS
   In the dermis, they serve to provide
    nourishment.
   ARTERIOLES are involved in body temp.
    maintenance
   Increased body heat results in
    vasodilatation, increased blood flow and
    loss of body heat to air or clothing
   Decreased body temp results in
    vasoconstriction with <blood flow and
    <loss of body heat
     SUBCUTANEOUS TISSUE
   Located BETWEEN dermis and
    muscles
   Made up of areolar connective tissue
    and adipose tissue
   Contains numerous WBCs (fights
    pathogens invading through the skin)
   Adipose tissue cushions some bones,
    provides for some insulation,but
    MOST IMPORTANTLY, provides for
    STORAGE OF FATS for energy needs
                  AGING

   EFFECTS OF AGING ON THE SKIN IS
    QUITE VISIBLE
   Cell division in the epidermis slows.
   Fibroblasts in the dermis die, don‟t
    regenerate
   Hair and skin much thinner
   Collagen/elastin fibers deteriorate
   Sebaceous and sweat glands
    decrease activity
   Skin frail and dry
   Less subcutaneous fat
   Temperature regulation labile in hot
    or cold weather; more sensitive to
    changes
   Melanocytes die, hair goes to gray
      NURSING ASSESSMENT
Skin problems are common complaints
   May be only complaint or may be a
    manifestation of underlying systemic
    condition/psychological stress
   Visibly communicates the clients‟ health
   WHATSUP questions
   INSPECTION AND PALPATION
   Phys. Assessment includes skin,hair
    nails,scalp, and mucus membranes.Client
    must be fully disrobed but draped for
    privacy
   Well lit and warm room
   Nl skin is intact, warm, smooth, dry,
    well hydrated, with firm skin turgor.
    Surface is flexible and soft
   Know color ranges
   Know developmental changes
   Inspect for color,
    moisture,lesions,edema, breaks in
    skin integrity, vascular markings,
    turgor, and cleanliness
                  COLOR
                  obj. #6
   Factors include temp of client, O2
    level, blood flow, exposure to UV
    rays, positioning, genetic differences
   Pallor; a decrease in color due to
    vasoconstriction, decreased blood
    flow or < HgB
   BEST ASSESSED ON FACE,
    CONJUNCTIVA, NAILBEDS AND LIPS
   Erythema; reddish discoloration, also may
    indicate circulatory changes due to
    vasodilation, incr. blood flow to skin from
    fever or inflammation
   BEST ASSESSED ON FACE OR AREA OF
    TRAUMA/RASH
   Jaundice (yellow-orange) may occur as
    result of liver disease.
   BEST ASSESSED IN SCLERA OF THE EYE
   Cyanosis; bluish discoloration
   Cardiac, pulmonary or perfusion problem
   BEST ASSESSED LIPS, NAILBEDS,
    CONJUNCTIVA, PALMS
   People of mediterranean descent, may
    have nl bluish on lips coloration
   Brown coloration due to increased melanin
    prod. Could be from chr. exposure to sun
    or due to pregnancy or PVD
   BEST ASSESSED FACE, AREOLA,
    NIPPLES, AND AREAS EXPOSED TO SUN
                 LESIONS
                  obj. #7
   Any change or injury to tissue
   Assessment may help determine cause of
    skin disorder
   Class. As primary; secondary
   PRIMARY represent initial reaction to a
    disease process
   SECONDARY lesions are the changes that
    take place in the primary lesion from
    infection, scratching, trauma or various
    disease stages
         PRIMARY LESIONS
   Macule; flat, non-palpable, usually
    smaller than 1cm; freckle
   Papule; palpable, solid raised lesion;
    wart, ringworm;1cm or less
   Nodule; solid raised lesion, larger
    and deep; fibroma
   Vesicle; small fluid filled blister type
    lesion; 1cm; chicken pox
   Bulla; larger fluid filled blister;>1cm, burns
   Pustule; sm. elevation of skin, vesicle or bulla that contains
    lymph or pus; impetigo/acne
   Wheal; round transient elevation of the skin caused by
    dermal edema; white in the center and red in the
    periphery; hives, insect bites
   Plaque; PATCH, solid or raised lesion on skin OR mucus
    membrane >1cm in diameter; psoriasis
   Cyst; CLOSED SACK OR POUCH; contains solid, semi-solid
    or liquid material; sebaceous cyst
       SECONDARY LESIONS
   Scales
   Crusts
   Excoriations
   Fissures
   Ulcers
   Lichenification
   scar
             configurations
   Discrete
   Grouped
   Confluent
   Linear
   Annular
   Polycyclic
   Arciform
   reticular
   NOTE:
   Color
   Size in cm
   Location
   Distribution
   Configuration (pattern)
   Exudate (amt., color, odor, any other s/s)
   Read how lesions may present in peoples
    of color
   Check levels of hydration
   Dryness, moisture, scales and flakes
   Moisture within skin folds
   Should normally be smooth and dry
                PALPATION
                  OBJ.#8
   Utilized in conjunction with INSPECTION
   Dorsum of hand for temp.
   Palpate lesions with fingertips to deter.
    Size, contour, consistency
   Note level of discomfort with palpation
   Wear gloves
   Turgor/texture
   Back of forearm, over sternum (best for
    elderly)
   Tenting with gradual return= poss.
    Dehydr., aging
           Vascular marking
   Normal
   Abnormal (petechiae, ecchymosis)
   Petechiae sm. Purplish hemorrhagic
    spots <0.5cm
   Seen best on dark skinned persons
    on conjunctiva and oral mucosa
   Ecchymosis is a bruise; coloration
    changes
                 edema
   Dependent edema; part of body at
    lowest point; feet , ankles, sacrum
   Often relieved with elevation and
    repositioning, elastic stockings,
    medications
   Brawny edema
   Pre-tibial edema
   Edema
   Occurs due to build up of fluid in the
    tissues
   Skin becomes stretched, taut and
    shiney
   Location, distribution and color are
    determined and documented
   If unilateral, compare to other side
   Measure to track progression or
    regression
   When suspect edema, palpate for
    tenderness, mobility, and consistency
   Pressure from finger/thumb 5sec. leaves
    indentation (pitting edema)
   Classified by depth
   1+=1mm depth or “trace” edema
   2+= 2mm or small amt. edema
   3+=moderate edema
   4+ large amount of edema
                   hair
   Hair distribution is palpated
   Quantity, thickness, and texture
   Note any areas of ALOPECIA
   Terminal hair is hair of scalp,
    eyebrows, axillae, pubic areas in
    both sexes and facial and chest hair
    with men
   VELLUS hairs are soft downey
    covering body
   Normally has uniform distribution
   Scalp hair can be thick, thin, coarse,
    shiney, curly, straight
   Describe distribution and cleanliness
                  NAILS
   Reflect general health
   Color, shape, texture, thickness, any
    abnormalities
   Normally pink, smooth, hard, slightly
    convex (160 degree) with firm base
   Elderly: yellowish-gray, thickening,
    ridges
   Brown or black pigm. between nail
    and nail base In persons of color is nl
   Abnl findings include clubbing (poss.
    Hypoxia)
   Spoon nails (concave)(koilonchia); poss.
    Anemia
   Thick nails; (poss. Fungal infection)
   Observe for redness, swelling, tenderness
   Beaus‟ lines
   Splinter hemorrhages
   paronychia
            Diagnostic tests
                obj.#9
   Cultures to show presence of
    bacteria, fungi, viruses
   fungi: specimen in 10% KOH;
    remains at room temp until sent to
    lab
   viral: fluid gently expressed from
    intact vesicle with sterile swab,
    special culture tube MUST BE KEPT
    ON ICE until sent to lab ASAP
   See box 50-2 for instr. On wound
    cultures
                Skin biopsy
   Indicated for deeper infection
   Eval. For dx and/or efficacy of current tx
   Excision of small piece of tissue
   Punch bx: plug of tissue for full thickness
    specimen
   Incisional bx: deep incision with scalpel
   ALWAYS REQUIRES CLOSURE WITH
    SUTURE
   Shave bx removes area of skin just above
    rest of skin
   All bx require sterile field/technique
   Prepare client
   Most painful part is ususally injection
    of local anesthetic
   WOODS‟ LIGHT is use of UV rays to
    detect fluorescent substances in hair
    and skin that are present during
    certain diseases such as tinea capitis
    (ringworm)
   Hand held black light in darkened
    room
               Skin testing

   Patch and scratch when allergic
    dermatitis is suspected
   Done by dermatolgist on uninvolved
    skin/upper back, arms, must be
    shaved
   SCRATCH; superficial scratch or prick
    with allergen; IMMEDIATE REACTION
   Wheal= + reaction
   MUST HAVE RESUSCITATION EQUIP
    AVAIL.
   PATCH test: delayed hypersensitivity
   Develops in 48-96h
   Allergens applied under occlusive
    tape patches
   Review procedure
   Final reading in 2-5 days
           Therapeutic measures
                 obj.#10
   Wet compresses for acute, weeping, crusted,
    inflammatory, ulcerative lesions
   Decrease inflammation, cleanse and dry the
    wound
   To continue drainage from the area
   Can be ordered as sterile or clean procedures
   Cool tap H2O, Burrows, normal saline,
    magnesium sulfate
   applied q3-4 h for 15-20min
   Not prescribed for more than 72h/skin too dry or
    macerated.
   For cool compr. Reapply q 5-10min
   Balneotherapy: therapeutic baths
   Medicate large areas of skin, remove
    old medications, debridement,
    relieve itching and inflammation
   Lasts for 15-30min.
   Bathmats are important
   Water/saline for weeping, oozing,
    and erythematous lesions
   Colloidal baths for wide area of lesions, to
    dry and relieve itching
   Medicated tar baths for chronic eczema
    and psoriasis
   Need WELL VENTILATED ROOM
   To increase hydration of skin after bath,
    use lubricating agent applied to damp skin
   An EMOLLIENT is used for LUBRICATION
    AND TO RELIEVE ITCHING
         Topical medications
   Include lotions, ointments, creams,
    gels, pastes, intralesional therapy
   May need systemic medications as
    well
   Review how and why each type of
    medication is used and how applied.
   Powders should not be used with
    clients with respiratory or traches
                 DRESSINGS
   Used to enhance absorption of topical meds,
    promote retention of moisture, prevent
    evaporation of medication, reduce pain and
    itching
   Occlusive drsg; to seal wound; airtight plastic
    film placed over topical agent
   Tube gauze, cotton socks, gloves, etc.
   Medication may be impregnated within drsg
    (chordran tape
   Review nursing care plan for client with occlusive
    drsg (50-3)pg 946
   Applied ONLY to wound area, not healthy skin
   Transparent dressings,
    (Opsite,Tegaderm)
   Hydrocolloid protect areas exposed
    to pressure, and treat ulcers in
    beginning stages
   Gels, pastes, granules to fill in deep
    wounds/ulcers to promote
    granulation and healing
    TYPES OF TREATMENTS AND
       REMOVAL OF LESIONS
   Moh‟s chemosurgery technique;
    method of excising tumors of the
    skin, done in layers until entire
    tumor removed. Insures complete
    removal of the tumor. Helpful in tx
    of basal cell cancers (pg 1375
    Tabers)
   Cryosurgery; use of extremely cold
    probes to destroy unwanted, or
    cancerous or infected tissues
    (508,T.)
   Photochemotherapy; use of light and
    chemical together to treat certain
    conditions such as psoriasis or
    cutaneous T-cell lymphoma
            WOUND HEALING
               OBJ#11
   HEAL BY :
   FIRST INTENTION; SECOND INTENTION
    AND THIRD INTENTION
   Edges approximated and closed with
    sutures= 1st intent; minimal scarring.
   2nd intent=wound left open to heal by
    granulation; scarring may be extensive
   3rd intent=infected site may be left
    open/reopened until all signs of infection
    are gone, then surgically closed
    NSG CARE FOR OPEN LESION
   Assess site minimum 3x day (4h x3)
   Assess for dead tissue, maceration,
    exudates,
   Cleanse, pat dry
   Apply agent and occlusive drsg
   REMOVE for 12h out of 24h
   Assess/eval
    forprogression/regression
   REVIEW ALL LEARNING TIP BOXES
   REVIEW ANY BOXES WITH
    INFORMATION IN THEM
          PRESSURE ULCERS
             OBJ.#12-14
   SORE CAUSED BY PROLONGED
    PRESSURE AGAINST SKIN in one
    position
   Weight of body compresses
    capillaries against a solid object,
    especially over bony prominences
   Results in tissue anoxia
   Start to develop in 20-40min.if
    pressure not relieved
   Assess at risk client
   Use Braden scale or similar scale
   Assess labs for low serum albumin,
    anemia, level of immobility and
    incontinence
   Other causes include tight splints, casts, traction
   At risk are the immobile, decreased sensation,
    decreased circulation, decreased neurological
    function
   Mechanical forces are friction, shear and
    pressure.
   When pressure to the skin is greater than the
    capillary bed pressure, there is impairment of
    cellular metabolism with decreased blood supply
    to cells causing tissue ischemia.
   The reduction in blood flow causes
    BLANCHING.(LOSS OF COLOR)
   “FRICTION” rubbing of skin surface with
    an external mechanical force.giving the
    effect of sheet burns.
   “SHEARING”occurs when pt slides down
    or is pulled up without lifting buttocks.
    Skin and subcut. tissues remain
    stationary; fat, muscle and bone shift in
    direction of body‟s movement
   Damage occurs deep in tissues
   Prolonged pressure occurs in the
    elderly due to nl skin changes
   The obese, because fat cells are
    poorly vascularized, the thin,
    because there is little padding over
    prominences, and those with
    impaired peripheral circulation
           Signs and symptoms

   Pain at ulcer site
   Freq. assess at common sites: sacrum,
    heels, elbows, lateral malleoli, greater
    trochanters, ischial tuberosities
   Describe according to “3” color system
      “blackened” tissue=necrosis
     „yellow” color and with
    exudates=infection present
     “red”wounds are pink/red and are in the
    healing stages
   Treat worst color first
   Dead tissue must be removed first or
    healing will not take place
              Interventions
                 obj.#13
   Box 51-1avoid use of soap and water
    on dry skin
   Clean and dry between toes
   Perineal cleansers
   Moisturizing agents without alcohol
   Avoid areas of pressure,don‟t
    massage areas of redness
   Assess for areas of redness, if stage
    1, initiate turn/position schedules
   Short fingernails
   Use of pillows, pads to maintain good body
    alignment. Use of specialty mattresses, pads to
    decrease pressure
   Encourage activity. Continue to assess skin and
    position
   Teach patient to shift weight q15min. When lying
    or sitting
   If immobile, needs freq. active/passive ROM
   Provide high protein, vitamin rich diet
   Braden scale to assess for risk
   Heels should not rest on bed
   Avoid source of any pressure behind
    calves if using pillows to elevate heels
   Use protectors to alleviate pressure on
    vulnerable sites
   NEVER USE A “DONUT”
   Avoid allowing skin surfaces to rub
    together
   Use trapeze, draw sheets to move pt in
    bed
   Complications are wound infections,
    progression to a deeper, larger
    wound
          DIAGNOSTIC TESTS
   All considered to be colonized with bacteria(
    bacteria present); wound not necessarily
    “infected”
   Cleansing and mech. debridement can prevent
    progression to infection
   Swab cultures; cultures for sensitivity done to
    identify causative agent from suspected infected
    sites
   Must determine between infection and bacterial
    colonization. If wound is healing by 2nd intention,
    will be colonized by flora on skin and in
    environment. If growth exceeds local tissue
    defenses, then becomes a true infaction
   When ulcer not healing, invasive/non-
    invasive blood supply studies are
    recommended
   Wound biopsies may be obtained in the
    case of large, extensive wounds
   Medical treatment varies with size, depth
    and stage of ulcer, pt condition.
   ALL PRESSURE MUST BE REMOVED FOR
    HEALING TO OCCUR, cleanliness
    maintained
   Debridement, cleansing and wound drsg.
    To provide moist, healing environment
   Debridement: removal of non-viable
    tissue from the wound
   Non-surgical means: mechanical,
    enzymatic, autolytic
   Mech.; scissors/forceps;
    dextranomer beads; whirlpool baths;
    wet to dry saline gauze
   Results in non-selective debridement
   Usually very painful; pt needs premed
   Enzymatic proteolytic agent; selectively
    digests necrotic tissue. Requires very
    careful application. Will digest living tissue
    also
   Autolytic; use of synthetic dressing; a
    moisture retentive drsg. Eschar is
    self digested due to enzyme action. NOT
    USED FOR INFECTED WOUNDS
   SURGICAL debridement removal by
    scalpel, of devitalized tissue, thick
    adherent eschar.
   May need a graft to close wound,
    espec. For full thickness ulcer or loss
    of joint funct involves a donor site
   Needs continual assess for pain
    during procedure
            Wound cleansing
   Should be cleansed with whirlpool or
    shower head/irrigation with between 4-
    15lbs per sq. inch(psi)
   Less than 4psi does not effectively
    cleanse. Greater than 15psi may damage
    good tissue
   If wound debris or light layer of eschar
    present, use 30ml syringe with 18g
    needle/250ml of NS
   This pressure will also remove bacteria
   If wound healing and tissue is red ( sign of
    new granulation tissue), use 30-60ml
    NEEDLELESS syringe to prevent trauma to
    new fragile tissue. After cleansing/dbr.
    Apply occlusive drg
   Wounds need moist env, minimal bacterial
    colonization and a healing temp; takes
    12h to occur.if freq removed, may not
    reach healing temp
   Infected wounds are NOT covered with
    occlusive
           Wound dressings
   Vary according to size, location,
    depth, stage of ulcer
   Commonly used materials; hydrogel,
    polyurethane, hydocolloid wafers,
    biologic agents, alginates and cotton
    gauze
   Use hypoallergenic tape to secure
   PRESSURE MUST BE KEPT OFF OF
    ULCER
         Nursing assessment
   Ongoing assessment
   Recognize causative factors and any
    impediments to healing
   Wound measurements including
    depth
   Probe gently with q-tip to detect and
    measure tunneling
             Wound staging
   1; skin intact but red and does NOT
    blanch; may have warmth, hardness
    and deeper tissue damage
   2; break in skin with PARTIAL
    THICKNESS LOSS OF
    EPIDERMIS/DERMIS. Appears as a
    shallow crater, abrasion, or a blister
   3; full thickness skin loss that extends to
    the subcutaneous tissue, BUT NOT THE
    FASCIA. There may be undermining of
    adjacent tissue. Looks like a deep crater,
    may have eschar
   4; full thickness loss with damage into the
    muscle, bone, other support structures.
    May have undermining and sinus tracts
   Assess the wound exudate
   Will be serosanguiness or may be purulent
   Purulent may have color and odor
    depending on the infecting agent
   Yellow = staph
   Beige and fishy=proteus
   Green-blue /fruity=pseudomonas
   Brown/fecal=bacteroides
   Assess for granulation
   Should be pink/red and slightly
    spongey
   Assess ulcer min. q24h; color , size,
    exudate
   Assess pt temp
   Provide wound care/sterile technique
   Assess pt for pain/can pt sleep, eat
      Inflammatory skin problems
              dermatitis
              obj15-17
   Char. by itching, redness, lesions of
    varying sizes and distribution
   Often caused by exposure to
    allergens, irritants,: can be
    precipitated by emotional stress and
    genetic factors
   Eczema ( non-specific term) and
    dermatitis used interchangeably
   Contact dermatitis: acute/chronic
   Caused by DIRECT CONTACT WITH
    IRRITATING SUBSTANCE; SOAP,
    MEDICINE
   Allergic: contact with an allergen resulting
    in A CELL MEDIATED IMMUNE RESPONSE
   Atopic: chronic, inherited, assoc with
    asthma. Lesions often become lichenified
    and hyperpigmented
   Seborrheic: chronic inflammatory,
    see seborrhea,excessive production
    of sebaceous secretions ( scalp face,
    axilla, genitocrural areas), greasy
    scales,yellow or pink-yellow crusts
   Assoc. with emot. Stress, often a
    genetic pre-disposition
   3 types are common
   Atopic, contact, seborreic
   Chronic, usually respond to tx, but
    recur
   See preventive measures
   Present as dry flakey scales, yellow
    crusts, fissures, macules, papules
   Worsen with continued irritation and
    exposure to offending agents
   Dx based on hx, s/s, clinical findings.
   Review table 51-1
   Tx based upon s/s
   Control itching, pain, decrease
    inflammation, control or prevent
    crust formations, prevent further
    skin damage, infection
   Measures to control s/s are:
   Use of antihistamines, anti-puretics and
    analgesics to control itching and pain
   Use of steroids topically, intralesionally or
    systemically to control inflammation
   Topical is preferred as systemic use over
    the long term can cause side effects and
    adrenal suppression

   Read page 325 in Davis 10 th edit. For s/e
    to corticosteroids
   Use “whatsup for nsg assess. Be sure to
    include assessment for altered body image
   Review your NANDA dx; impaired skin
    integrity, disturbed body image, and defic.
    Knowledge related to disease and tx
   Goals of tx to keep skin intact, or improve,
    prevent infect., maintain comfort
   Give me at least 10 questions with
    rationales from whatsup, 50-1
   Display an accepting attitude
   Teaching for how to apply medications,
    robin
   How are you able to measure your goals
    for effectiveness of tx
   Controlled or in remission, itching or
    discomfort minimal, able to socialize, pt
    able to describe and demonstrate self care
                Psoriasis
   Chr. Inflammatory disorder in which
    the EPIDERMAL CELLS proliferate
    abnormally fast. Ordinarily takes 27
    days. With psoriasis, takes only 4-5
   The abnl keratin forms loosly
    adherent scales on reddened base
   Exacerbations/remissions
   Cause unknown, but has large
    familial component
   Onset can be any age with 27y being
    the average
   Severe if starts in childhood
   Sun /humidity may suppress
   Strep pharyngitis, stress, hormonal
    changes, weather, skin trauma and
    meds ( antimalarials, beta blockers
    and lithium) may exacerbate
   No known true prevention, but avoid
    stress, meds, trauma, resp. infections if
    poss.
   s/s vary with type of psoriasis
   Lesions usually are red papules that join
    to form plaques with DISTINCT BORDERS
    silvery scales form on untreated lesions
   Most affected areas are: ELBOWS, KNEES,
    SCALP, UMBILICUS, GENITALS
   May see nail involvement, dry, brittle hair
   Complications may include secondary
    infections, psoriatic arthritis
   Systemic s/s and lymphadenopathy
   Tests would depend on severity
   Usually done on phys. Findings
   Testing done to dx a concurrent
    disease or secondary infect.
   Anthralin, a strong irritant, may be used
    with salicylic acid as a paste.
   Can cause a chemical burn, not on for >2h
   Used with tar and UV light under close
    medical supervision
   UVB (short wave) and UVA (long wave)
    amount of exposure dtermined by pts
    condit., pigmentation and susceptibility
   Occlusive drsgs enhance penetration
    of meds
   Keratolytics enhance effects of
    salicylic acid to loosen, remove
    scales
   Tars are usually prescribed along
    with steroids. Tars act to slow cell
    division in the epidermal layers
   Never use occlusive drsgs with tars
   Must WEAR EYE GUARDS during tx
   PUVA tx is oral Psoralen used in conjunct
    with UVA tx. This tx temporarily inhibits
    DNA synthesis
   Pt MUST WEAR DARK GLASSES DURING
    TX AND FOR ENTIRE DAY AFTER TX.
    Longterm effects are unknown. Possible
    incr. risk of skin cancers, premature aging
    and actinic keratosis
   Observe pt closely for redness,
    tenderness, edema and eye changes
   Depending upon pt condition, initial and
    f/u eye exams, skin bx, urinalysis and
    blood work may be ordered
   Antimetabolites..a last resort
   Methotrexate most common agent, can
    lead to hepatotoxicity. Liver bx and labs
    are routinely done prior to tx.
    Contraindicated in persons with any liver,
    renal or bone marrow disease
   Nursing care would be the same as
    for any pt with a dermatitis, but be
    sure to emphasize freq. periods of
    rest to enhance the antimitotic
    effects of the medications
   Usually females pred. In males, often
    have Rhinophyma (enlarged,
    redenned/purplish nose
   Heat/cold, spicey foods
   Avoid temp. extremes/alcohol/stress
                 Rosacea
   Chronic acneform disorder of face
   Increased reactions of capillaries to
    heat
   Often exists with acne
   Often cause of significant facial
    cosmetic disfigurement
   Age 30-50y
    INFECTIOUS SKIN DISORDERS
   Impetigo contagiosa
   Common , infectious, inflammatory
    skin disorder
   Strep or staph
   Pools, pets, dirt fingernails,
    contaminated materials, or
    secondary to scrapes, cuts, etc.
   Primary infection appears on
    exposed areas, extrem., hands, face
    , neck, skin folds
   OOZING, THIN ROOFED VESICLE
    that grows rapidly and produces a
    HONEY COLORED CRUST; EASILY
    REMOVED, replaced with new ones
   Heal in 1-2wks if allowed to dry
           COMPLICATIONS
   GLOMERULONEPHRITIS FROM A
    PARTICULAR STRAIN OF STREP(PG 599)
   EASILY SPREAD TO OTHER PARTS OF
    BODY
   Will persist if lesions not allowed to dry
   Secondary PYODERMA..ACUTE ,
    INLAMMATORY PURULENT DERMATITIS, if
    lesions not responsive to tx
              TREATMENT
   SYSTEMIC ANTIBIOTICS
   TOPICALANTIBIOTICS AFTER REMOVAL OF
    CRUSTS
   Gentle washing with mild soap and warm
    water to remove crusts
   Antipyretics
   Clean hands/nails, mitts, GOOD HYGIENE
   REMAIN HOME UNTIL ALL LESIONS ARE
    HEALED
   Observe for 6-7 weeks for s/s glomerular
    nephritis
          HERPES SIMPLEX
         common viral infection
   Hsv1 and hsv2
   HSV-1 occurs above the waist,
    typical cold sore on mouth
   HSV-2 occurs below the waist and
    causes genital herpes
   Primary infection occurs thru direct
    contact, respiratory droplet or
    exposure to fluid filled vesicles
   Lies dormant in nerve ganglia near the
    spinal cord…immune system can‟t destroy
    it. At this time, pt has no s/s, may first
    present with pain , itching, burning at site
    of breakout
   Recurrence is spontaneous; stress,
    lowered immune, fatigue, injury
   Secondary lesion may be single or as a
    group of vesicles or pustueles on an
    erythematous base
   Crusts form, dry, heal in approx. 1 wk
   LESIONS ARE CONTAGIOUS for 2-4
    days before dry crusts form
   Can be red lesions without vesicles
   Virus sheds
   Avoid contact with a known infected
    lesion during the blistering phase can
    prevent the primary infection
   Attacks diminish with
    age..contagious until scabs form
   If herpes simples is present in the
    vagina at childbirth, the newborn
    may be infected and develop
    meningoencephalitis or panvisceral
    infection
   If rub lesion and rub eyes, can
    develop HSV infection in eyes,
    possible blindness, brain infection
   Culture provides definite dx
   Usual dx based on s/s, hx
   NO COMPLETE CURE
   Topical acyclovir drug of choice to tx primary
    lesions to suppress multiplication of
    vesicles.DOES NOT WORK ON SECONDARY
    LESIONS.
   Oral acyclovir may be recommended for severe
    or freq. attacks.; people who are immunocompr.
    Creams. Ointments may be prescribed to speed
    drying, healing..may need addit. Of oral
    antibiotics
   Nursing education of pt is PRIMARY
    IMPORTANCE; INSTRUCTION ON
    HOW TO AVOID INFECTION, WHEN
    IT IS CONTAGIOUS, AND how to
    prevent spreading to other body
    parts
        Furuncles and carbuncles

   Furncle; small tender boil; occurs deep in
    one or more hair follicles, spreads to
    dermis
   Usually caused by Staph
   Areas of excessive perspiration, friction
    and irritation
   Yellow, black or whitehead
   Pain, tenderness, erythema, surrounding
    cellulitis, poss. lymphadenopathy
   Carbuncle; extension of furuncle
   Abscess of skin and subcutan. Tissue
   Where skin is thick, non-elastic,
    fibrous
   Upper back, back of neck, buttocks
   Fevers , pain, leukocytosis, collapse
   Debilitated clients and diabetics
   Furuncles can progress to carbuncles
   Systemic infection
   Can spread infection to others
    (staph)
   Scarring can occur, may require I&D,
    and systemic antibiotics
DO NOT SQUEEZE AND IRRITATE
Use antibacterial soaps to cleanse/ointment
Surg. I&d
Cover lesion with DSD
DOUBLE BAG ALL SOILED DRESSINGS
Analgesia/antipyretics
Bed rest advised with carbuncles/or furuncles
  located in the perineal/anal areas (Forniers‟
  gangrene)
Cleans living area and equipment daily, laundry
  after each use
Strict hand washing
            HERPES ZOSTER
              (SHINGLES)
   Different virus than HSV
   This is caused by Varicella zoster, thought
    to be identical to virus causing chickenpox
   Presents as acute, inflammatory and
    infectious outbreak of painful vesicles on
    erythematous base. Out break occurs
    along the dermatone(s) of one or more
    cutaneous sensory nerves
   Usually unilateral
   Thought to be a reactivation of latent
    zoster virus
   Incubation 7-21 days
   Vesicles appear in 3-4 days
   Eruption generally occurs posteriorly
    and progresses anteriorly and
    peripherally along the dermatone
   Duration can vary from 10days to 5+
    weeks
   Occurs most commonly in elderly
   Or immune suppressed, immun-
    suppr. Agents or with malignancies,
    injuries to spine or cranial nerves
   Avoid contagion by avoiding contact
    with person with this disease.
   Contagion possible a few days before
    eruption of vesicles and until dry
   May present with vesicles and plaques
   Irritation, itching, fever, malaise
   May be very painful, pain likely to increase
    with age of pt and remain after healing in
    the elderly
   Condition referred to as hyperesthesia;
    any measures to increase comfort should
    be used; cold compresses
   Dx by clinical presentation and
    assoc. s/s. may do cultures for
    suspected secondary infection
   If in more than two dermatones, pt
    will need isolation room in hospital
   Some evidence can be airborn
               complications
   Post herpetic neuralgia
   Persistent dermatomal pain, can last for
    months and years. Can have severe
    negative impact on quality of life
   Opthalmic herpes zoster affects 5th cranial
    nerve; serious complication, can lose
    sight, hearing loss, facial paralysis, vertigo
   Full thickness skin necrosis and systemic
    viremia
   Can cause chickenpox in others
                    Treatment
   Aimed towards controlling s/s and preventing
    complications. Should start within 72h
   Acyclovir, topical, oral, IV may be used at initial
    outbreak, early stages as well as Famciclovir and
    Valacyclovir
   Doesn‟t cure, but helps suppress the viral
    outbreak
   Analgesics for pain; of limited value,
    corticosteroids to reduce pain, but NOT with
    opthalmic involvement. Topicals, tricyclics,
    anticonvulsants
   Antihistamines, antibiotics, medicated baths
   Only reliable way to differentiate
    from HSV is culture, serum PCR/IFA
   Use of new vaccine, Zostavax in
    people age 60 and younger
        FUNGAL INFECTIONS
   DERMATOPHYTOSIS a fungal infection of
    the skin that occurs when there is a break
    in skin integrity in the presence of warmth
    and moisture.
   Occurs with direct contact with infected
    humans ,animals or objects
   TINEA IS THE OPERATIVE NOUN.
   The second name stands for the body site
    affected
   TINEA pedis(athletes foot), common.
   Chronic plantar scaling, acute vesicular,
    and interdigital
   Chronic plantar scaling in fold lines,
    itching not usually present
   Acute vesic. Eruption of tiny painful itching
    blisters
   Interdigital, common form, erosion,
    scaling, fissuring in toe webs, painful,
    burning, itchy with offensive odor
   Chronic planatr treated with
    keratolytics, topical antifungals. NOT
    CURATIVE
   ACUTE SOAKS OR BATHS 2-3X DAY
    TO DRY BLISTERS astringent paint
    applied to unroofed blisters
   Interdigital treated with
    combinations antifungals, antibiotics
    and foot soaks with Burrows
   Pt teaching important
   Feet dry, avoid plastic/rubbersoled
    shoes
   Water shoes in public showers
   Cotton socks to absorb perspiration
   Tinea capitas; ringworm of scalp
   Contagious; loss of hair in children
   Presents as scattered round red scaly
    patches, may have small pustules
   Brittle hair at site, breaks off, mild
    itching and kerion inflammation
   Treat with systemic antifungals
    because of high relapse rate with
    just topicals
   Highly contagious
   Teach med side effects, never share
    combs, headgear, pillows, brushes
   Check pets for s/s of infection
   Tinea corporis; ringworm of body
   Erythematous macule that
    progresses to rings of vesicles, alone
    or in groups, on exposed areas of
    body, may be intensely itchy
   Infected pets are freq. source
   Topical/oral antifungals, topical
    steroids
   Keep skin dry, wear cotton
   Tinea cruris (jock itch)
   Ringworm of groin may extend to
    inner thighs and buttocks. Often
    present along with tinea pedis
   Small scaly patch, then sharply
    demarcated plaque with elevated
    scaly or vesicular borders
   May be intensely itchy
   Teach to avoid heat, moisture,
    friction
   Topical anitfungals; spread beyond
    lesion borders
   Oral antifungals/steroids may be
    needed to control/cure
   Remember to discuss possible med
    side effects, short and long term with
    client
   Tinea unguium (onychomycosis)
    fungal infection of fingernails and
    toenails
   Usually lifelong
   Yellow thickening of nailplate,
    crumbly debris; nail plates become
    separated, eventually nail is
    destroyed
   Topicals usually not effective
   May need nail avulsion (removal)
   High rate of relapse
                CELLULITIS
   Inflammation of skin cells and or cellular
    or connective tissue from a generalized
    infection with Staph or Strep
   Result of skin trauma or secondary
    infection of an ope wound, or may have
    no immediately known cause
   Most freq. occurs in lower extremities
   Good hygiene and prevention of cross
    contamination
   Presents with warmth, pain, edema,
    erythema, tenderness, fever locally
    and progresses rapidlyif not treated
   C&S of pustule or lesions to identify
    organism. May need blood cultures if
    bacteremia suspected
   Always be aware of your patient‟s
    immune status
   Topical and oral or IV antibiotics
   Get good hx; recent trauma?, abnl
    temp, v/s
   Use of good hand hygiene at all
    times for you and the patient, wash
    linens and clothes
   Much CA-MRSA now
          ACNE VULGARIS
   COMMON SKIN DISORDER OF THE
    SEBACEOUS GLANDS
   Occurs freq. on upper back, face,
    shoulders, whereever there are
    numerous hair follicles
   Multifocal causes, often hormonal
   Sebaceous glands under endocrine
    system control; androgens
   Stimulation of glands causes more
    sebum to be produced
   This with grad. Obstr. Of
    pilosebaceous ducts with debris,
    leads to inflammation and rupture of
    seb. Gl.
   This leads to greater infl., formation
    of pustules, nodules and cysts
   Hereditary factors, stress, strong
    soaps contribute
   NOT RELATED TO CHOCOLATE, DIET,
    CLEANLINESS
   Can occur regardless of interventions
   Initial lesions are comeodones,
    closed whiteheads, lead to open
    lesions with blackheads, lipids and
    melanin pigments
   Effective topical agents; benzol peroxide,
    an anticiotic, erythromycin and
    tetracycline(teeth)to kill bacteria in
    follicles
   Vitamin A acid (retin-A to loosen pore
    plugs and prevent new form.
   Antibiotics usually reserved for severe
    cases, espec Retin-A must be closely
    monitored
   Must be tested to be sure not pregnant,
    use 2 forms of birthcontrol 1 mo before,
    during and after
           Parasitic disorders
              infestations
   Infestation by lice
   Pediculosis capitas,corporis, pubis
   Bite skin and feed on human blood
   Leave eggs and excrement
   Causes intense itching
   Lice are oval and 2mm in length
   P. capitas, female lays eggs(nits)
    close to scalp hair and behind ears
   Silvery white
   Transmitted dy direct contact with
    infested organisms or
    objects(fomites)
   Most common in children and people
    with long hair
   May not be itchy
   P.corporis; body lice that lay eggs in
    seams of clothing, then pierce skin
   Neck, trunk thighs
   Intense itching, excoriations
   P. pubic(crabs) usually in genital area, but
    can be hairs of chest, axilla,eyelashes,
    beard
   Often thru sexual contact,less often
    infested bed linen
   Intensely itchy
   Prevent by avoiding contact with
    infested persons/objects
   Don‟t share equip.,routine washing
    of clothing
   Secondary infections/impetigo, boils
   Mrsa
   Parallel linear scratches,Hyperemia,
    hyperpigmentation
   Can be vectors for rickettsial diseases
   Through hx and exam, may also want to
    test for STDs
   Pediculocides/nix
   Complications with other meds
   Goal to kill the parasites and
    mechanically remove nits
   Use of pediculocides ie permethrin or
    pyrethrum are commonly used
   Some lice may exhibit resistance
   “NIX” or permethrin active for
    approx. 1wk, kills adult lice
    immediately and nits as they hatch
   Rid, A-200 pyrinate must be re-
    applied in one week
   Physostigmine opthal. Oint to
    eyebrows, lashes, no other meds
   Nursing care; give full instructions on
    the medications used, possible side
    effects, how, when and where the
    medication is used and for how long.
   How to remove nits
   How to remove lice from body, hair
    and linens
   Children out of school until
    adequately treated
                SCABIES
   Contagious and caused by Sarcoptes
    scabiei
   Intimate or prolonged contact with
    infected clothing, bedding, animals
   Mites burrow into superficial layers of
    skin; show as short, wavy brown or
    blacklines.
   Most contagious at this time, but pt
    may be asymptomatic
   s/s may not appear for 4 wks
   Mites live for 24h only without
    human contact
   All infected Persons and animals
    need to have tx at same time
   Linen and clothing washed, but
    furniture does not require cleaning
   s/s = itching and rash, espec. At
    night. Itching starts 1mo after
    infestation and may continue for
    days and weeks after tx
   Signs may be concentrated in webs
    of fingers, axilla, wrist folds, groin,
    genitals, excoriations from scratching
   On penis, groin
   Hypersensitivity to mite can result in
    crusted lesions, infection
   Dx confirmed by superficial shaving
    of a lesion and microscopic eval. For
    mites, eggs or feces
   Topical scabicides are used for disinfection
   Entire body, neck to feet and folds, left on
    for 8-12h, then washed off. One tx usually
    suffic. If not re-infected
   Caution pt that itching may return after tx
    until the allergic reaction subsides
   Dead mites remain in theepidermis until
    exfoliated
               PEMPHIGUS
   Acute or chronic serious skin disease
    characterized by the development of large
    bullae on normal skin and mucus
    membranes, usually affects older
    poulation
   When they rupture, leave open, raw,
    painful, eroded, oozing partial thickness
    wounds, that form crusts
   Originates in the oral mucosa and spreads
    to the trunk, involving large areas of body
   May also experience pain, burning,
    itching and may develop foul smell
   Interferes with chewing, talking,
    swallowing, pt miserable
   Likely to develop a secondary
    bacterial infection..high mortality
    rate with this disease
   Dx by +Nikolski‟s sign (sloughing or
    blistering of nl skin when pressure
    applied)
   Bx will reveal acantholysis
    (separation of epidermal cells from
    each other
   Medical Tx consists of trying to
    control s/s and infection, body fluid
    and protein losses, promote healing
   Corticosteroids in large doses,
    cytotoxic agents, analgesics,
    antipyretics
   Needs high protein/high calorie diets
    to maintain nutrition and fluid
    replacement
              Nursing care
   Educate pt on effects and side effects
    of medications
   Maintain I&O, body wt, b/p
   Potassium permanganate baths to
    cleanse, disinfect and remove odors.
    Thoroughly dissolve these crystals
   Offer fluids, provide appropriate
    psycho-social support
   At risk for   alterations in self image
   At risk for   nutritional deficits
   At risk for   infections
   At risk for   alterations in fluid/electrolyte
    balance
   At risk for   medication side effects of
    steroids
   At risk for   alterations in comfort
   At risk for   grief reaction/mortality
               BURNS
    pages967-976 ; 278-288 in PEDS
   Wounds caused by energy transfer from a
    heat source to body tissue, causing tissue
    damage
   Infants under age 2 and adults over age
    60 have highest mortality rates
   Heat denatures proteins and interrupts
    blood supply
   3 zones of tissue damage
   EPIDERMIS; hyperemia; no interruption of
    blood supply; no cell death; area least
    affected by heat
   DERMIS; stasis injury; temp. incr. on
    tissue edema; vasoconstriction,
    sludging of red blood cells; red, +
    blanching; fragile area prone to
    necrosis/infection
   SUBCUTANEOUS TISSUE;
    coagulation injury; irreversible cell
    death; white/gray; no blanching
   Damage related to: temperature of agent,
    type of agent, length of exposure,
    conductivity of tissue, thickness of tissue
    involved
   Loss of large areas of skin= loss of
    protective functions, impaired temp.
    regulation, possible infection, loss of
    fluids, sensory deficits, impaired skin
    regeneration, impaired
    secretory/excretory function
   Alterations in skin function affects most all
    body systems
   Increased capillary permeability leads to
    leakage of plasma and proteins into
    tissues; leads to edema and loss of
    intravascular volume (HYPOVOLEMIA)
   Evaporative water loss, greater than 4-
    15x nl
   Incr. metabolism= incr. water loss thru
    resp. system
   Cardiac funct.; decre.output, that worsens
    due to lower circ. Plasma vol. As plasma
    leaks into interstitial tissues,for first 48h,
    leads to severe hypovolemia; if untreated,
    hypovolemic shock. At risk for 72h after
    burn. Must have fluid replacement. There
    is an increase in Hct., and red blood cell
    destruction; decreases platelet function
    (pg 367)intravenous fluids as ordered,
    check urinary output, likely will require
    indwelling catheter
   Increased metabolic demands; body
    maintains high metabolic rate for healing

   Severe catabolism (breakdown of body
    tissues and cellular structures) results in
    neg. nitrogen balance, wt. loss, and decre.
    Wound healing
   Stress triggers elevated catecholamine
    levels (epinepherine, norepinepherine)
    which causes elevated glucagon levels and
    hyperglycemia
   GI problems ie. Gastric dilation,
    Curling‟s ulcer (peptic ulcer from
    stress), paralytic ileus, and superior
    mesenteric artery syndrome
    (intestinal angina from occlusion)
   Acute renal insufficiency
   Electrical burns can result in tubular
    necrosis as a result of myoglobin
    casts (muscle damage)
   Pulmonary effects mostly related to smoke
    inhalation, and very common in burns to face and
    chest. Hyperventilation in proportion to severity
    of burn Incr. O2 consumption. Rapid
    swelling/edema of the respiratory passages,
    hoarse voice. Elevate head of bed to 30 degrees,
    continuous assessment, provide O2, prepare pt
    for intubation if nec.
   Immune system severely compromised from loss
    of substantial portion of skin barrier and first line
    defense macrophages.
   Common burns
   Thermal/steam/scalds
   Radiation
   Chemical; acids or alkali, cancause skin and
    pulmonary burns; dry chemicals must be brushed
    off
   Flames
   Contact
   Electrical; more serious than appears; lightening
    in excess of 50,000 degrees; may present with
    feathery, branching appearance
          Burn classifications
   Partial thickness (1st-2nd degree)
   Superficial; comprised of epidermis,
    poss. Papillae of dermis
   Bright red to pink, blanches, fluid
    filled blisters, glistening, moist
   Very sensitive to air , temp. and
    touch
   Heals in 7-10 days
   MINOR BURNS
   15% of TBSA NOT involving face ,
    hands, genitalia or
   Full thickness burn less than 2% of
    TBSA
   Partial thickness (deep; 2nd degr.);
   Appendage usually involved
   ½-7/8 dermis
   Blisters may be present
   Pink, light red, white, blanchable
   Exposed nerve endings
   14-21 days for healing
   May need grafting to prevent scars
   MODERATE BURNS
   15-25% of TBSA or
   Full thickness burns that are 10% of
    TBSA
   Full thickness (3-4th degree)
   Epidermis down thru bone
   3rd degr. Involves entire dermis and
    portions of subcutaneous tissue, fatty
    tissue showing
   Red, Snow white , gray, brown, leathery,
    dry
   Nerve endings destroyed, no pain unless
    close to lesser degree burns
   Needs grafting
   MAJOR BURNS
   Partial thickness burn greater than
    25% of TBSA or
   Full thickness burn involving greater
    than 10% of TBSA or involving face,
    hands, feet or genitalia
                  sizing
   Done by rule of “nines” or Lund and
    Browder chart
   Figure 51-11, see difference in adult
    and child configurations on “nines”
   This formula NOT accurate in
    formulating burn percentages for
    children, so note differences
         Common labs ordered
   Dx thru clinical manifestations and hx
   labs: CBC,BUN, fasting glucose,
    electrolytes,
   ABGs, pulse oximetry
   Blood protein; albumin
   Urinalysis; specific gravity
   Ekg
   Bronchoscopy
   Pulm. Funct, (spirometer, lung vol,
    diffusion capacity(body‟s ability to extract
    O2 from lungs)
          Emergent phase
onset of injury to completion of fluid
            resuscitation
   BURNING PROCESS MUST BE STOPPED/REMOVE
    VICTOM FROM SOURCE OF BURN. and airway
    patency ,breathing, and circulation assured
   Assess percentage and depth of burns (#2)
   Clothing must be removed and jewelry (#1)
   Wound is cooled with tepid water only if TBSA is
    10% or less, however,lavage for 20min. Needed
    for chemical burns.dry chemicals must be
    brushed off. Use precautions
   Person covered with sterile or clean sheet to
    decrease shivering/contamination
   DO NOT APPLY ICE
   Assist in wound
    debridement/medicate for pain prior
    to txs
   Assess for hypovolemia (decreased
    B/P, incr. HR, and respirations)
   Monitor ABGs, and
    carboxyhemoglobin levels
   Initiate intravenous access, USUALLY
    LACTATED Ringers, 0.9% saline or plasma
   Possible need for TPN
   Monitor v/s; CLOSE, ACCURATE I&O
   Maintain NPO
   Insert indwelling catheter
   Administer pain medication as prescribed
   Administer Tetanus toxoid as prescribed
   Monitor extr for any circumferential burns
   Check extremities for any
    circumferential burns. Will act like a
    tourniquet, causing compartment
    syndrome/respiratory insufficiency.
    Pt will need an escharotomy; incision
    thru eschar and superficial fat.
   Common sites are extremities, trunk
    and chest
   Patients, especially children, may
    quickly become hypervolemic (within
    24-96h) even to having pulmonary
    edema
   Sterile technique/hand washing
   Prevent infection/sepsis
            Stage 2 (acute)
      from start of diuresis to near
      completion of wound closure
   Goals are wound closure
   No infections
   Minimum scarring/lack of contracture
   Maintainance of comfort
   Adequate nutrit support
   Dialy wound cleansing and
    debridement
   MEDICATE FOR PAIN
   Hubbard tank or showering for
    cleansing
   Debridement; mech. Chemical,
    surgical or combination
                Dressings

   Open or closed, biologic or synthetic
    or combo
   Open involves topical agent no
    dressing
   Closed involves occlusive drsg over
    the wound
   Limit bulk
   No skin surface to surface; donut gauze
    around ear
   Base drsgs on wound size, absorption
    needs, protection and type of debridement
    being done
   Wrap extremities DISTAL TO PROXIMAL
   ELEVATE ALL AFFECTED EXTREMITIES
    ABOVE LEVEL OF HEART
      BIOLOGIC DRESSINGS
   TISSUE FROM LIVING OR DECEASED
    HUMANS OR ANIMALS
   These dressings may be used as
    donor site dressings; to manage a
    partial thickness burn and cover a
    clean, excised wound before
    autografting
   Assist with wound healing and
    stimulate epithelialization
   Synthetic dressings
   Are used in management of partial
    thickness burns and donor sites
   More available, less costly, easier to
    store than biologics
   Variety of materials and sizes
   Rarely contain antimicrobial agents
   Biologic and synthetic dressings are
    TEMPORARY wound coverings for
    clean partial- thickness AND full
    thickness injuries
   Maintain wound surface until healing
    occurs, a donor site is available or
    wound is ready for autografting
          SKIN GRAFTING
   Autograft is skin graft from the
    PATIENT‟S unburned skin to be
    placed on clean excised burn site
   2 types; STSG (.006-.016) and FTSG
    (.035-.040) inches in thickness
   STSG includes epidermis and part of
    dermis
   FTSG includes epidermis and entire
    DERMAL AREA
   STSG may be applied as a sheet graft or
    meshed graft
   Sheet graft used primarily for cosmetic
    effect; face, chest, breasts , or hands,
    placed on as a full sheet
   Meshed graft, tiny splits, looks like
    fishnet; allows skin to expand 1.5-9 times
    its original size
   Allows for coverage of large area with
    small piece of skin. Good for extensive
    burn areas
   Graft take or revascularization in 3-5 days
   Disadvantages include:
   Prone to chronic breakdown
   More likely to hypertrophy
   More likely to contract
   FTSG can be sheet grafts or pedicle
    flaps
   Used over areas of muscle mass, soft
    tissue loss, hands feet, eyelids
   Pedicle attached to blood supply and
    area to area in need of grafting
   Pedicle not used for extensive
    wounds; not as popular as free skin
    grafts
   FTSGs allows more elasticity over joints
   Soft, pliable
   May allow hair regrowth
   Provides good color match
   Less hyperpigmentation
   Donor sites take longer to heal
   Requires split-thickness graft to heal or
    closure from wound edges
           Promoting factors
   Adequate hemostasis
   Anatomic location of graft
   Smooth contour
   Non-joints
   Graft well secured
   Immobilization of graft area
   Good nutitional status
             Inhibiting factors
   Infection
   Necrotic skin
   Location on perineum, axilla, buttocks
   Poor quality donor skin
   Poor nutritional status
   Bleeding
   Mechanical trauma
   Shock+
             DONOR SITES
   Donor sites are considered to be PARTIAL
    THICKNESS WOUNDS
   Try to get healed in 10-14 days, but many
    variables affect this time-table
   Nursing considerations include promoting
    comfort, preventing trauma and infection
   Outer dressing to apply pressure to
    maintain homeostasis remains in place 1-
    2 days. Dry exposure may require
    avoidance of pressure, and a heat lamp
    60-100wts, KEPT 2 FEET AWAY FROM
    SITE. Loose separating gauze is trimmed
            MUST KNOW
   THE DONOR SITE IS VERY PAINFUL
   THE GRAFT SITE MUST BE KEPT
    IMMOBILE UNTIL THE GRAFT TAKES.
   SKIN GRAFT MUST NOT SLIP
   GRAFT SITE DRESSINGS MAY BE BULKY
    AND MUST NOT BE DISTURBED
   MUST HAVE FREQ. CIRC. CHECKS AND
    ANY INVOLVED EXTREMITY MUST BE
    ELEVATED
   GOAL: GOOD ADHERENCE OF GRAFT
    AND NO WOUND INFECTION
        MEDICATIONS USED
   Silver sulfadiazine: buttered on, covered
    with a light dressing 1-2x day
   Broad spectrum, low toxicity, Can still
    have burning sensation can be used
    with/wo dressings
   Intermediate penetration of eschar
   Leukopenia (fever, sore throat, cough)
   Thrombocytopenia (easy bruising, unusual
    bleeding)
   Sulfamylon: buttered on 3-4x day
   Broad spectrum, rapid deep penetration of
    eschar, excreted rapidly
   Causes pain with application
   Pulmonary toxicity, metabolic acidosis,
    may inhibit wound healing
   With any sulfa med, may have adverse
    reaction, Stevens- Johnson
    syndrome,MUST MAINTAIN ADEQUATE
    FLUID INTAKE
   Silver Nitrate solution: wet dressing
    change BID, resoak q2h; broad
    spectrum, nonallergenic, low toxicity,
    inexpensive, won‟t interfere with
    healing
   Poor penetration of eschar;
    ineffective on established wound
    infections
   Bacitration: buttered on q4-6h
   No pain, odorless, softens eschar,
    but..poor penetration of eschar.
    Ineffective on established wound
    infections
   Gentamicin: apply gently 3-4x day
   Broad spec., covered or left open
   Ototoxic, nephrotoxic, pain with
    application
   Nitofurazone: THIN LAYER dierectly
    on wound or impregnate gauze.
    Change drsg. BID,
   Broad spec., bacteriocidal
   PAINFUL APLLICATION
   May support overgrowth of fungus
    and/or Pseudomonas
              STAGE 3
    from wound closure to return of
     optimum function on all levels
   Rehabilitation
   therapy STARTS IN ACUTE PHASE
    CONTINUES THRU REHAB
   Reconstructive can take many years
   2 major nsg considerations; the most
    comfortable position is the position
    of CONTRACTURE and the burn site
    will contin. to shorten until it meets
    an opposing force
   MAJOR GOAL IS TO AVOID CONTRACTURE
   Exercise program within 24-48h
   Use of splinting devices for positioning and
    stretching ie pressure garment
   Great psychosocial effect
   Important to return to abilities of preburn
    level. Requires work of many disciplines
    and the patient
            Nursing process
   Assessment includes: medical hx,
    known allergies, current medications
    if any,
   Extent, depth, burn agent, duration
    of contact, location of pain, level of
    pain, associated injuries
   Determine first aid needs
   Additional losses, how burn ocurred
            Nursing diagnosis
   Primary are:
   Impaired skin integrity
   Impaired gas exchange
   Deficient fluid volume
   Ineffective tissue perfusion
   Imbalanced nutrition
   Activity intolerance
   Selfcare deficit
   Disturbed body image
   Ineffective coping
   Deficient fluid volume
   Check urine output/replacement 50ml/h in
    adults; HR AT NL TO 100BPM, stable body wt
   Wt daily
   Record I&O, insert indwelling catheter
   Assess for s/s
    hypovolemia(<b/p,tachycardic,tachypneic,
    thirsty, restless, disoriented)
   Monitor/review labs (electrolytes and CBC)
   Assess urine specific gravity and for
    hemochromogens(indicate renal tubular necrosis)
   Administer osmotic diuretics
   Assess gi funct.for paralytic ileus
   Maintain nasogastric tube/tube
    patency
Impaired gas exchange related
   To upper airway edema, carbon
    monoxide poisoning, edema of
    capillary aveolar membranes
   Goal: pt will have patent airway; CO
    level< 10%, clear lung sounds, PAO2
    80-100mmhg; PACO2 35-45 mmHg,
    alert and aware
   No s/s stridor, nasal flaring,
    retractions
Pain related to burns or graft donor
                sites
   Pt will have good pain control as
    evidenced by verbal and non-verbal
    cues
   Does pt verbalize this, how many
    hours of sleep in 24h, does he/she
    feel rested
    Risk for sepsis related to wound
                infection
   Pt will not develop a wound infection
   Healthy granulation tissue?
   Unhealed, open area with <10
    colonies of bacteria
   Donor sites free of infection?
   Did graft take
   Nl temp/nl WBC?
             Skin lesions
   Non-cancerous
   Premalignant
   malignant
   Benign include: cysts, seborrheic
    keratosis, keloids, pigmented
    nevi,which must be watched for
    change in color or moles>1cm, size,
    inflammation, itching, oozing,
    bleeding, varigated colors(bluish),
    irregular borders, warts,
    hemangiomas
           Malignant lesions
   Basal cell carcinoma arises from
    basal cell layer of epidermis
   Most common type
   Sun exposed areas on body
   Rolled waxy edge, depressed center,
    can be pearly, crusting and
    ulceration
   Rarely metastatic, but can be locally
    invasive/disfiguring
   Squamous cell ca., also from epidermis
    and sun exposed areas of skin and the
    mucus membranes
   Lower lip, neck, tongue, head and dorsa of
    hands, poss. develops on preexisting
    lesion (actinic keratosis)
   Single crusted, scaled, eroded papule,
    nodule or plaque, fragile, prone to oozing,
    bleeding
   Highly invasive with mets
   Malignant melanoma
   Malignant growth of pigment cells
   Highly metastatic/high mortality rate
   Can occur anywhere on body
   Many arise out of pre existing moles
    or nevi
   Three types:
   Lentigo maligna; slow growing dark
    macule on exposed skin surfaces (face of
    elderly pts) irreg. borders, brown, black,
    tan. Prognosis good if treated early
   Superficial spreading; most common type,
    can occur anywhere on body espec of
    elderly; slightly elevated plaque with irreg
    border, varies in color, may bleed or ooze
   Eventually develops into a nodule
   Prognosis is poor at this stage
   Nodular melanoma appears suddenly
   Spherical papule or nodule on skin or in a
    mole
   Color blue-black, blue gray, reddish-blue
   Fragile, bleeds easily
   Mets occurs rapidly, least favorable
    prognosis
                   prevention
   Prevention is primary
   Limit or avoid direct exposure to UV rays, sun
    (10a-2p), tanning booths
   Wear sunblock 15 or>
   Protective clothing
   Self examination weekly/monthly
   See md for suspicious lesions or changes. Have
    moles or nevi in areas of constant friction
    removed
   Fair skinned people, and/or those with a lot of
    moles, freckles be more cautious, less melanin
    protection
   Preliminary based on presentation of
    lesion
   Definitive from biopsy; further
    testing done if +
             Miliaria rubra
   Prickly heat
   Pinsized erythematous papules
   Sweat glands, folds
   Itching
   Prevention
   No bundling
   Tepid baths
             Diaper rash
   Rash from ammonia
   Burning erythematous rash
   Must consider yeast
   Primary is prevention
   Expose to air
   Avoid baby powders
   Wash and dry thoroughly
              C. albicans
   Causative agent for thrush and some
    “diaper rash”
   If mother has vaginitis
   Milk curds
   Antibiotic therapy
   Mycostatin/nystatin q6h, thin layer
   Cleanliness/open to air as much as
    possible
                 impetigo
   Superficial bacterial infection
   In newborn/staph aureus
   Older child group A beta-hemolytic
    strep
   Newborn presents as
    bullous(blisters)
   Older child non-bullous
   Highly infectious Follow skin/contact
    precautions
   Gown and gloves
   Infant needs to be segregated from others
   Appears on face, spreads, crusts and
    drainage are contagious
   Soak off crusts, follow with
    Bacitracin/neosporin
   Careful handwashing
   Older child treated in home with careful
    teaching of caregivers
   Very itchy, trim nails Medical
    treatment can be Peniciilen or
    erythromycin for ten days
   Daily wash off crusts,/bactroban
   ****If older child and organism is
    strep, infection can be rheumatic
    fever or acute
    glomeruloephritis*****
        Acute infantile eczema
   Atopic dermatitis often as a result of
    reaction to an irritant
   Common first year of life, after 3mos
   Uncommon in breastfed babies
   Hereditary predisposition
   Hypersensitivity in deep skin layers
    to protein or protein like allergens
   Allergens may be inhaled, ingested,
    absorbed thru direct contact
   House dust,mites, egg white , wool
   Infants may develop hay fever or
    asthma later in life
   Starts on cheeks, spreads to
    extensor surfaces of arms and legs,
    then entire trunk
   Initially red skin, then papule and
    vesicle formation
   INTENSE ITCHING causing weeping
    and crusting, may quickly become
    infected by strep or staph
   Common allergens are foods; egg
    whites, cows milk, wheats, orange
    juice, tomato juice
   Inhalants, dust , pollens, animal
    dander
   Materials; wools, nylons, plastic
   Dx, by process of elimination
   Elimination diet/ assess often for s/s
    malnutrition
   Serious condition eczema vaccinatum
   High mortality rate
   Avoid herpes infection/exposure
   Severe pain and illness
   Treatment may include oral
    antibiotics, antihistamines, sedatives
   Cortisone creams only if there is no
    infection, wet soaks (colloidal), tepid
    water, emollients
   Parents are exhausted, frustrated
   Usually clears by age 2
          Nursing diagnoses
   Impaired skin integrity
   Disturbed sleep
    patterns(itching/discomfort)
   Imbalanced nutrition (elimination
    diet)
   Risk for infection
   Deficient knowledge of caregivers
                 goals
   Preserve skin integrity
   Maintain comfort
   Maintain good nutrition
   Prevent infection
   Increase family/caregiver knowledge
   What are the interventions available to
    implement goals?
   Cover skin, prevent scratching, wet
    dressings, don‟t allow to dry
   Weighing daily****
   Aseptic technique/avoid hospitalization
   Read labels carefully
   Instruct caregivers/ provide
    support/referrals to community services
   Small papule on scalp;spreads
   Griseofulvin drug of choice.
    Compliance difficult due to tx of
    3mos
   Corporis lesions on body
   Usually from infected dog or cat
   Miconazole, clotrimazole
   T. pedis, hygiene, meds, white socks
   T. cruris
      Fungal infections (pg 406)
   Tinea, fungal infection living in outer
    layers of hair, skin, nails
   Ringworm of scalp, tinea
    capitis/tonsurans
   Transmitted person to person
   Microsporum canis/animal to child
   Hair brittle and breaks off easily
           Parasitic infections
   Pediculosis and scabies
   Suck blood of hosts
   Capitis, corporis, pubis
   Human to human
   Severe itching
   Kwell shampoo for at least 4min, rinse,
    dry, dip comb in warm white vinegar
   Wash all in hot wter and dry in hot dryer
   Dryclean non-washables
   Seal in plastic bags for 2 weeks to
    break cycle
   All in contact 30-60 days, treat
           Drugs affecting skin
   TERMS
   Antiseptic: chemicals applied to living
    tissue to kill pathogens that may harm the
    host
   Disinfectants: chemicals used to kill
    organisms present on objects
   Bacteriostatic: halts or slows growth
    without killing off entire population
   Bactericidal: will kill bacteria, not fungus,
    spores or viruses
              Types of drugs
   I. Topical anti-infectives
      Topical antibiotics
      Topical antifungals
      Topical antivirals
   II.Topical antiseptics and germicides
   III.Topical corticosteroids
   IV.Topical antipsoriatics
    V.Topical enzymes
    VI.Keratolytics
    VII.Topical local anesthetics
           Topical antibiotics
   Exert direct local effect on specific
    organisms
   Can be bacteriostatic/bactericidal
   Used to prevent superficial infections
    in minor breaks in skin integrity
   Bacitracin; 1-5x day
   G-myticin; 1-5xday
   Emgel; 2x day
   Neomycin; 1-3x day
   Thin layers
   All have significant side effects
               antifungals
   Interrupts the continued growth of a
    fungus after long period of use
   Used for jock itch, athletes foot,
    ringworm, candidal infections of skin,
    vagina and mucus membranes
   Fungizone (amphetericin B),
    Miconozole (Micatin), ciclopirox
    olamine (Loprox)
    Econazole(spectazole)
   Tolnaftate (tinactin), Nystatin (Nilsat
    and Mycostatin)
                 antivirals
   2 available are acyclovir (Zovirax)
    and penciclovir (Denavir) inhibit viral
    replication
   Acyclovir for initial outbreaks of
    genital herpes and for Herpes
    simplex viral infections in
    immunocompromised clients
   Penciclovir only for HSV 1( Herpes
    labalis adults
    Adverse reactions of topicals
   Can cause hypersensitivity reaction
   Superinfection (overgrowth of organisms
    not affected by med)
   Topical antibiotics are category C for
    pregnant women..used cautiously during
    pregnancy and lactation
   Topical antivirals are Cat. B, still used with
    caution
   Topical antifungals unknown except for
    Spectazole (cat. C) and ciclopirox
    (penlac)(cat. B)
    Topical antiseptics/germicides
   Exact action not known; affect a
    variety of organisms
   Efficacy may depend on strength,
    concentration and length of exposure
    with skin or mucus membrane
   Used to reduce numbers of bacteria
    on skin surfaces
   Benzalkonium,chlorhexidine, Iodine
   Have few adverse reactions unless
    individual has an allergy
   Contraindicated if known hypersens
    otherwise, no significant reasons to
    avoid use
        Topical corticosteroids
   Vary in potency, vehicle for delivery,
    and area of skin to which it is applied
   Exert a local anti-inflammatory effect
   Useful in relieving itching, redness
    and swelling from psoriasis,
    dermatitis, rashes, eczema, insect
    bites, first and second degree burns
   May cause same symptoms
    supposed to relieve
   Don‟t give with known
    hypersensitivity
   Not for use as monotherapy in
    bacterial skin infections or viral
    infections
   Limit or avoid use on face, eyes
   Preg. Category C
        Topical antipsoriatics
   Drugs help to remove plaques
    Anthralin (Anthra-derm) and
    calcipotriene ( Dovonex)
   Don‟t give with known hypers.
   Category C
             Topical enzymes

   Aids in removal of necrotic tissue by
    reducing proteins into simpler tissue
    (proteolytic action)
   Responders may be second/third degree
    burns, pressure ulcers and ulcers of PVD
   Collagenase/Santyl
   Low incidence of adverse reactions
   Not for use in wounds where nerves are
    exposed or wounds connect with a body
    cavity. Cat. B, may be inactivated by
    detergents and antiseptics
               keratolytics
   Acts to remove excess growth of the
    epidermis
   Warts, calluses, corns, and
    seborrheic keratosis
   Salicylic acid, diclofenac (solaraze)
    and Actinex, salicylic acid often in
    OTC preparations
   Usually well tolerated
   Don‟t give with known hypersen.
   Not used on moles, warts with hair,
    genital or facial warts, warts on
    mucus membranes or infected skin
   Not for longterm use in diabetics,
    clients with impaired circulation or
    infants
   Cat. C
       Topical local anesthetics
   Temporarily inhibit conduction of
    impulses from sensory nerve fibers
   Relieve itching, burning and pain
   Can be used with caution on mucus
    membranes
   Lanacane, nupercainal, Xylocaine
   Occas. local irritation noted
   Contraind. With known hypers. And
    with certain class 1 antiarrhy meds
            Nursing process
   Pre-administration assessment consists of
    visual and palpation, describe using
    appropriate terminology
   Ongoing assessment of site every
    application; checking for changes or
    adverse reactions
   Apply nursing diagnoses
   Planning for expected outcomes
   Implementation to promote an
    optimal response to therapy
   Allow for time to verbalize concerns
    or ask questions
   Assure condition improves, if true
   Topical antiinfectives
   Cleanse skin with soap and warm
    water
   Apply medication thin layer, liberally
   Either cover or leave exposed
   Avoid eye area
   Topical antiseptics and germicides
   Instill or apply as directed
   Occlusive dressing only if ordered
   All containers must be clearly labeled
    and dated, more advisable not to
    leave on bedside table, espec. With
    elderly or confused pt
   Educate pt to any special effects of
    med, iodine may stain, etc
   Topical corticosteroids
   Wash site with soap/water unless
    otherwise directed
   Applied sparingly. If to have
    occlusive drsg, apply while skin still
    moist, cover with plastic wrap
   Topical enzymes to remove dead
    tissue
   Certain skin wounds may require
    special preparation,
   Area is washed or cleansed
   Med applied as dir
   If bleeding occurs, d/c and rept
   Avoid application to healthy tissue
   Topical antipsoriatics
   Apply only to prescribed areas
   Assess for intensified irritation
   Educate pt on s/e and limitation to
    sunlight exposure
   Topical anesthetics
   Advise pt of numbness which can last
    an hour or so
   If used on mucus membranes, advise
    no food for at least I hr, may have
    impaired swallow

								
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