NUR 105Care of Patients with Integumentary Disorders and Burns

Dermatitis

Delayed allergic response involving cell-mediated immunity.

Inflammatory disorder results Atopic- Affects bout 10% of

population involves mast cells Stasis Dermatits- occurs on legs as a

result of venous stasis and edema

Dx and Tx

Dx-Inspection and History, Possible exposure. Atopic seem to have genetic

Tx-avoidance of irritant, good skin care, control of inflammation

Corticosteroids topically or orally Caution with creams

Acne

Characterized by papules and pustules over the face, back and shoulders.

Vulgaris- More common begins in puberty, continues thorughout teen years then subsides

Occurs when the ducts leading form sebaceous glands beome plugges with sebum

Onset related to sex hormones

Acne Vulgaris Tx

Dx- History and Exam Tx- Topical

Retinoic Acic- Retin A• Best agent for papular lesions

Benzoyl peroxide both prescription and non precription strength.

Azelex- BID

Acne Vulgaris Tx PO

Tetracycline and EES- Topical and PO Isotretinoin-Accutane

All patients experience some side effects Taken 2-4 months inhibits sebaceous glands Effects months to years after DCD Accutane is used only for sever cystic

acne that is resistant to all other treatment. There are serious adverse side effects, including organ damage!

Dermabrasion

Tx for pitting and scarring of cystic acne.

Automatically scaping away the out layers of skin and smoothing out surface.

Acne Rosacea

Begins ages 30-50 Redness, Papules, pustules, and

telangiectases (a type of varicose veins also known as spider veins; small bluish-purple veins, usually found in clusters on the leg.)

Face over cheeks and bridge of nose Facial flushing precipitate worsening.

Tea, coffee, etoh (wine) caffeine, spicy foods, sunlight.

Acne Roscea TX

Manage Flareups MetroGel Sometimes Oral Antibiotics

Nursing Interventions Teaching

Not contagious Washing face with mild soap gently Do not squeeze blackheads spreads

infection and can press the sebum more firmly in the clogged duct

Support and Encouragement

Nursing Dx

Altered Body Image Infection R/T AMB Goals Interventions

Psoriasis Non contagious, chronic, and

recurring skin disorder Inflammed, edematous skin lesions

covered with silvery white scales Abnormal rapid rate of proliferation Bleeding occurs when scales are

removed. Palm and Soles affected

Psoriasis ADLS may be difficult Inflammations of the joints possible Genetic Predisposition Immunologic first lesion commonly

appears after an URI. T cells mistakenly activated

May pose greater risk for MI

Dx History and Physical Exam R/O other disorders Unpredictable goes into remission

spontaneiously Sometimes will clear up with or

without treatment

Psoriasis Tx Mild Cases

Steroid Creams• Kenalog (triamcinolone acetonide)• May become resistant

UV Rays• Extreme Can have opposite effect

Tar Preparations- psoralen• Impeded proliferation of skin cells• Baths, Topical applications, shampoos• May be used with UV- Called PUVA therapy but

hospitalization required due to exact dosing of two.

Nursing Management Keep skin moist and pliable as

possible. Humidifers to increase moisture

Any irritaiton or break in the skin seems to stimulate the growth of psoriatic plaques, avoid injury to tissues.

Psoriasis,

NANDA Psoriasis Imparied Skin Integrity Altered Body Image

R/T AEB Goals Interventions

Bacterial Infections Usually caused by Staph Infections

Cellulitis Furuncles Carbuncles

Cellulitis Deep subcutaneous infection of the skin typically by bacteria

that results in a localized area of erythema and inflammation.

Cellulitis most often affects the lower legs in adults as fissures in the toes (due to tinea pedis) provide a portal of entry.  The disease presents with the cardinal signs of inflammation: redness, warmth, swelling, and tenderness as well as with acute fevers.  Such inflammation permits bacterial infection of the dermis, and edema predisposes to bacterial infection.  The epidermis is usually unaffected, although rarely blisters are present. The causative agents include Group A Streptococci and Staphylococcus aureus.  In immunocompetent hosts, antibiotic therapy is most always curative

Cellulitis

Furnucles and Carbuncles thigh, or perineum;

Infection that occurs on the face, neck, axillae, buttocks, boils that tend to reoccur- they will drain pus; often produces scar tissue.

Viral Infections Verruca: Warts Herpes Simplex

TypeI – Face or Neck Type II- Genitialia

Varicella/Herpes Zoster Shingles- Variation of herpes zoster infection – may

develop years after varicella- lies dormant in nerve roots- may be triggered may impaired immune system- virus migrates along cranial or spinal nerve roots.

Herpes II Herpes I

Preventing Spread of Herpes Awareness of Disease Sexual Transmission Oral Herpes Autoinoculation is possible- spread from

what part of body to other per (auto) or self.

Either type can cause lesions in any part of the body, oral to genital, genital to oral.

Topical Anti-infectives: Actions and Uses (cont’d)

Topical antiviral drugs Inhibit viral replication Used to treat:

Initial episodes of genital herpes•Herpes simplex virus infections in immunocompromised patients

PO Treatment for Herpes Acyclovir (Zovirax) Famciclovir (Famvir) Valacyclovir (Valtrex)

Varicella Shingles

Shingles Signs and Symptoms Vague at first

Chills, low grade fever, GI disturbance Vesicles

Appear 3-5 days after onset Usually trunk first Blisters to Lesions on nerve pathway

• Painful and Itching

Dx and Treatment

Analgesic Capsaicin- OTC 5 times a day Pain is difficult to control- may need to

enhance with guided imagery/distraction

Early antiviral meds help prevent postherpetic pain syndrome

Danger of Herpes Zoster No one should be in contact with a

patient who has chickenpox or shingles if they have never had the disease.

Pregnant women should not care for the chickenpox patient or herpes zoster patient.

Contagious can harm fetus.

Topical Anti-infectives: Contraindications, Precautions, and

Interactions Contraindicated in patients with known

hypersensitivity to drugs or any components of drug Topical antibiotics: Used cautiously during

pregnancy and lactation Acyclovir and penciclovir: Used cautiously during

pregnancy and lactation

Fungal Infections Tinea Pedis Tinea Cruruis

Tinea Fungal InfectionsParasitic Fungi invade the skin,

scalp, Nails

Tinea Fungal infectionsTinea Cruruis Tinea Pedis

Tinea Capitis Tinea Corpois

Nursing Interventions for Fungal Infections

Keep area clean and Dry to avoid fungal infections

Apply medications as ordered Topicals, antifungal powders

Clean cotton clothing Do not share clothing or burshes Clean Towels Clean underclothes

ScabiesSpread by skin to skin contact. Caused by an itch mite.

Signs and Symptoms Severe Itching Especially after Hot shower Burrow between fingers and toes,

and groin Secondary Infection may occur

DxScabes Body Inspection Skin scraping of lesion under

microscope

Tx RID NIX Toxic to liver Clothing and Bedding Chairs etc.

Burns Injuries to skin caused by

agents such as heat, hot liquids, electricity, chemicals or radiation

Burns Greatest number

of burn injuries to adults associated with cigarette smoking and cooking

Burns Elderly likely to

suffer burns by spilling hot liquids on themselves or by catching clothes on fire as they cook or smoke

Burns Young children

especially prone to burn injuries from spilling scalding liquid on themselves or from playing with matches or lighters

Causes of Burns Flame-house fire Contact-hot tar,

metal, grease Chemical industry Electrical-one of

most serious- entrance and exit

Radiation – UV

Classification of BurnsBy Amount of Body

surface area injured

“Rule of Nines” a way of expressing portions of body surface burned

Head and neck – 9% Anterior trunk – 18% Posterior trunk – 18% Each arm – 9 % = 18% Each leg –18%= 36% Genitalia and perineum – 1%

Pediatric Classification Lund and Broder chart

gives accurate estimates of burn surface area involved in children less than five years of age

Depth of Burn-Old Method First degree:

involves epidermal layer only

Second degree:involves superficial to deep dermis

Depth of Burn-Old Method Third degree:involves

all layers of dermis, extends into subcutaneous tissues- absence of pain

Fourth degree: includes muscle and bone

Depth of Burn-New Method

BURN DEPTH AND OUTCOME                                                                      

SECOND DEGREE CAUSE APPEARANCE PAIN HEALING SCAR

SUPERFICIAL Hot liquid, short exposure Wet, pink, blisters severe 10-14 days minimal

MID-DERMALHot liquid, longer exposure, flash

flameLess wet, red blisters moderate 2-4 weeks moderate

INDETERMINATE(MID OR DEEP)

As aboveRed with patchy, white

armsmoderate 2-6 weeks moderate or severe

DEEP-DERMAL Chemicals, direct contact flames Dry, white minimal 3-8 weeks severe (needs graft)

INDETERMINATE(2nd OR 3rd)

Chemicals, flames Dry, white none   -----   -----

THIRD DEGREE(FULL THICKNESS)

Chemicals, flames, explosion, with very high temperature

Dry, white, or char none need graftmild to severe,

depending on timing and type of graft

Depth of Burn-New Method Partial

thickness:epidermal appendages (sweat and oil glands and hair follicles) intact-wound heals itself if no further injury occurs

Depth of Burn-New Method Full thickness:

involves all layers of skin and destruction of epidermal appendages and requires grafting for healing to occur

Assessment Pulmonary

involvement: respiratory wheezing or distress, redness of face and neck or cough and sooty sputum

Amount of DamageRelated to: Temperature of

burning Burning agent itself Duration of exposure Conductivity of tissue Thickness involved

Diagnostic TestsDone to determine

severity of burns CBC BUN ABG’s UA Total protein/albumin

gives info about nutritional status and body’s ability to maintain circulatory fluid

Treatment for Minor Burns Treat all burns as

trauma patients Treat with immersion

in cold water and application of cold compresses

Never apply salves or any greasy substances

Treatment of Major Burns Maintain patent airway - #1 priority LOC Maintain aseptic area Smother burns immediately Remove clothes and jewelry that might be

holding in heat if not adherent to skin Irrigate chemical burns with water Never try to remove clothes stuck to burn Use Poisoin Control

Emergent Stage (Shock) Anxiety, pain, fluid loss First 24-48 hours post burn,

fluid shifts from plasma to interstitial space

Potassium levels rise in plasma The first hour of treatment after

burning can be crucial to the outcome.

Escharatomy to prevent compartment syndrome may be done early. Used primarly with cirumfential burns and burns of the chest. Allows perfusion to burn areas. May be done in OR or at bedside

Check for return of pulses

Transer To Burn Center Partial-thickness and full-thickness burns greater than

10% of the total body surface area (BSA) in patients under 10 years or over 50 years of age. 

Partial-thickness and full-thickness burns greater than 20% BSA in other age groups.

Partial-thickness and full-thickness burns involving the face, eyes, ears, hands, feet, genitalia, or perineum or those that involve skin overlying major joints.

Full-thickness burns greater than 5% BSA in any age group.

Electrical burns, including lightning injury (significant volumes of tissue beneath the surface may be injured and result in acute renal failure and other complications).

Transfer to Burn Center Significant chemical burns.

Inhalation injury.

Burn injury in patients with pre-existing illness that could complicate management, prolong recovery, or affect mortality.

Any burn patient in whom concomitant trauma poses an increased risk or morbidity or mortality may be treated initially in a trauma center until stable before transfer to a burn center.

Children with burns seen in hospitals without qualified personnel or equipment for their care should be transferred to a burn center with these capabilities.

Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases involving suspected child abuse and neglect.

Burn Transfers ABC Transfer of any patient must be coordinated

with the burn-center physician.  All pertinent information regarding tests,

temperature, pulse, fluids administered, and urinary output should be recorded on the burn/trauma flow sheet and sent with the patient. Any other information deemed important by the referring or receiving physician also is sent with the patient.

Load and Go don’t stay and play

Fixed Wing may be available if rotor is not

Dedicated Trained Team not just a nurse in an ambulance or helicopter

A trained dedicated team in an ambulance in better than having a patient stay where his or her needs cannot be met.

Emergent Stage (Shock) Metabolic acidosis occurs Fluid loss-mostly plasma Insertion of 2 large venous IV (Not

22g)catheters – to provide electrolyte and fluid replacement therapy

Monitor V/S and I&O Prevent Hypovolemic Shock due to

circulatory collapse.

After first 24 hours

D5W for and adult D545NS for child Maintain NA level of 135-145 meq/l

Parkland Formula

4ml Ringer’s lactate X %burn X wt in kg One half within 8 hours of the burn Second half over the next 16 hours. Fluid replacement is calculated

from the time of injury not from the time of arrival at the medical facility.

Intake and Output

IV sutured in place Foley Catheter Minimum urine output for burn is 30ml/hr Child is .5ml/kg/hr

Post Shock Phase (Diuretic) Capillary permeability stabilizes-fluid

begins to shift from interstitial spaces to plasma

Potential dangers Hypokalemia Hypernatremia Hemodilution pulmonary edema

Post Shock Phase (Diuretic) Monitor CVP Observe labs Maintain urine output

Nursing CarePain Control Offer IV morphine Administer IV narcotics

10-15 minutes prior to painful procedure

Maintain normal body alignment

Alternating mattress-relieve pressure

Daily psychotropic drugs

Nursing CareFluids Continuous

replacement of lost fluids

Usually Lactated Ringers to maintain fluid balance and prevent shock

Monitor to prevent fluid overload

Nursing Care

Isolation Maintain reverse

isolation After 72 hours

postburn, the most common cause of deaths is infection

Nursing CareMaintain Function/Prevent

contractures Position of extension Not flexion = contractures Active exercises-provides increase in

circulation, improved muscle tone and prevents contractures

Painful as the motion of physical therapy exercises may be the muscles and skin must be exercised and stretched every day if normal motion is to be maintained.

Wound CareOpen Method Wounds left open to air in sterile setting Wet compresses/soaks to débride burn Skin easily inspected Cleansed daily Topical agent Q8 Non sterile gloves for washing wound Temperature and Electrolyte Loss

Wound Care-Open Method ROM exercises

easier to perform Temperature and

humidity of room must be carefully controlled

Reverse isolation may be required

Wound CareClosed Method Occlusive dressing with

silver sulfadiazine antibiotic cream to control infection

Painful and costly Decreases water loss Limits range of motion

exercise

Wound Care

Closed Method Less used than open

method Debridement of

wound Removes eschar Prevents infection

and tissue sloughing Healthy tissue may

be then grafted

Topical Applications Topical

preparations best applied with sterile glove

Strict aseptic technique

Mafenide (Sulfamylon) Basteriostatic-gram -

and + including pseudomonas

Penetrates tissue wall and thick eschar

Dressings not needed

Alternate use with Silvadene

Silvadene Broad antimicrobial activity Effective against yeast

(Candida) Can be washed off May cause skin rash

Bacitracin Minimal

antimicrobial activity

Useful in preventing drying of wound

Betadine Effective against a

wide variety of bacteria, fungi, yeast, viruses and protozoa

Can lead to elevated serum iodine levels when used in open wounds

Nutrition Immediately after severe

burn-TPN After 1st week-diet high in:

Protein CHO Vitamin C Fe Ca Needed for tissue cell

rebuilding and repair May require up to 5000

calories

Skin Grafting Graft-living tissue

transplanted to another area of body

Autograft-from same person receiving graft

The patients own skin is the only permanent graft material.

Homograft-donor person other than recipient

Skin Grafts Heterograft or

xenograft-donor animal -usually pig

Temporary graft-used to replace lost skin so that granulation may occur

Skin Grafting Split-thickness-less severe and

shallow burns Full-thickness-severe and deep burns Newly grafted wounds are best

treated with petroleum gauze occlusive dressings

Graft “take” or vascularization complete in 3-5 days

Skin Grafting Graft site must be

kept immobilized Donor site Partial thickness

wound heals 10-14 days

Bed Cradle Heat lamp

Donor Site

Full thickness

Donor Site

Burn on Calf after Skin Graft Applied

Calf Burn after stitches feel out post graft

Calf Burn after graft

Donor Site 2 Weeks

Problems Associated with Burns

Fluid and Electrolyte Imbalance

Edema appears around wound as a result of damage to capillaries

Loss of fluid at the burn area

Causes confusion, disorientation and decreased LOC

Problems Associated with Burns

Pulmonary Changes Most life threatening Caused from inhalation

injury Pulmonary edema Beware of Cough Watch for increasing

hoarseness, stridor and falling 02 saturation.

Pulmonary Changes Obstruction of air

passages from edema

Restriction of lung mobility from eschar on chest wall

Monitor and report diminished lung sounds and crackles

Problems Associated with Burns

Renal Changes In burns of 15-20%

of the body surface, decreased urinary output which must be avoided or reversed

UTI’s frequent

Problems Associated with Burns

GI Changes Acute gastric

dilation Paralytic ileus Curling’s ulcer

that produces coffee ground aspirant

Problems Associated with Burns Psychosocial Problems Provide emotional support

to client and family Maintain honest, open

approach with client and family

Teach client/family home care for D/C

Refer to support groups as appropriate

Managing Itch Nonpharmacologic measures to

reduce itching, such as relaxation techniques, meditation, guided imagery, and music therapy, are used along with pain medication.

Problems Associated with BurnsElderly Considerations Greater risk for

complications/delayed healing due to age related changes

Decrease renal blood flow and glomerular filtration-may lead to kidney failure

Elderly Considerations Impaired

circulation, tissue nutrition-may lead to unsuccessful skin graft

Stress may leave body unable to meet demands for increased oxygen and cardiac output