INTEGUMENTARY OBJECTIVES 1-11

1
INTEGUMENTARYOBJECTIVES 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
• 2 layers epidermis and the dermis

2
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 form
  calluses.

3

• 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

4

• 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.

5

• 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

6
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

7
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

8
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

9
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

10
Sebaceous glands andsudoriferous 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.

11

• 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

12
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 ltblood flow and ltloss of body heat

13
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

14
AGING

• EFFECTS OF AGING ON THE SKIN IS QUITE VISIBLE
• Cell division in the epidermis slows.
• Fibroblasts in the dermis die, dont regenerate
• Hair and skin much thinner
• Collagen/elastin fibers deteriorate
• Sebaceous and sweat glands decrease activity

15

• 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

16
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

17

• 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

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COLORobj. 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 lt HgB
• BEST ASSESSED ON FACE, CONJUNCTIVA, NAILBEDS AND
  LIPS

19

• 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

20

• 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

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LESIONSobj. 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

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PRIMARY LESIONS

• Macule flat, non-palpable, usually smaller than
  1cm freckle
• Papule palpable, solid raised lesion wart,
  ringworm1cm or less
• Nodule solid raised lesion, larger and deep
  fibroma
• Vesicle small fluid filled blister type lesion
  1cm chicken pox

23

• Bulla larger fluid filled blistergt1cm, 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 gt1cm in diameter psoriasis
• Cyst CLOSED SACK OR POUCH contains solid,
  semi-solid or liquid material sebaceous cyst

24
SECONDARY LESIONS

• Scales
• Crusts
• Excoriations
• Fissures
• Ulcers
• Lichenification
• scar

25
configurations

• Discrete
• Grouped
• Confluent
• Linear
• Annular
• Polycyclic
• Arciform
• reticular

26

• 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

27

• Check levels of hydration
• Dryness, moisture, scales and flakes
• Moisture within skin folds
• Should normally be smooth and dry

28
PALPATIONOBJ.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

29
Vascular marking

• Normal
• Abnormal (petechiae, ecchymosis)
• Petechiae sm. Purplish hemorrhagic spots lt0.5cm
• Seen best on dark skinned persons on conjunctiva
  and oral mucosa
• Ecchymosis is a bruise coloration changes

30
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

31

• 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

32

• When suspect edema, palpate for tenderness,
  mobility, and consistency
• Pressure from finger/thumb 5sec. leaves
  indentation (pitting edema)
• Classified by depth
• 11mm depth or trace edema
• 2 2mm or small amt. edema
• 3moderate edema
• 4 large amount of edema

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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

34

• Scalp hair can be thick, thin, coarse, shiney,
  curly, straight
• Describe distribution and cleanliness

35
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

36

• 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

37
Diagnostic testsobj.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

38
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

39

• All bx require sterile field/technique
• Prepare client
• Most painful part is ususally injection of local
  anesthetic

40

• 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

41
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.

42

• PATCH test delayed hypersensitivity
• Develops in 48-96h
• Allergens applied under occlusive tape patches
• Review procedure
• Final reading in 2-5 days

43
Therapeutic measuresobj.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

44

• 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

45

• 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

46
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

47
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

48

• 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

49
TYPES OF TREATMENTS AND REMOVAL OF LESIONS

• Mohs 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)

50

• 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

51
WOUND HEALINGOBJ11

• HEAL BY
• FIRST INTENTION SECOND INTENTION AND THIRD
  INTENTION
• Edges approximated and closed with sutures 1st
  intent minimal scarring.
• 2nd intentwound left open to heal by
  granulation scarring may be extensive
• 3rd intentinfected site may be left
  open/reopened until all signs of infection are
  gone, then surgically closed

52
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

53

• REVIEW ALL LEARNING TIP BOXES
• REVIEW ANY BOXES WITH INFORMATION IN THEM

54
PRESSURE ULCERSOBJ.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

55

• Assess at risk client
• Use Braden scale or similar scale
• Assess labs for low serum albumin, anemia, level
  of immobility and incontinence

56

• 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)

57

• FRICTION rubbing of skin surface with an
  external mechanical force.giving the effect of
  sheet burns.
• SHEARINGoccurs 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 bodys movement
• Damage occurs deep in tissues

58

• 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

59
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 tissuenecrosis
• yellow color and with exudatesinfection
  present
• redwounds are pink/red and are in the
  healing stages

60

• Treat worst color first
• Dead tissue must be removed first or healing will
  not take place

61
Interventionsobj.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,dont massage areas of
  redness
• Assess for areas of redness, if stage 1, initiate
  turn/position schedules

62

• 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

63

• 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

64

• Complications are wound infections, progression
  to a deeper, larger wound

65
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

66

• 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

67

• 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

68

• 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

69

• 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

70
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

71

• 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

72
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

73
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

74
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

75

• 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

76

• 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 fishyproteus
• Green-blue /fruitypseudomonas
• Brown/fecalbacteroides

77

• 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

78
Inflammatory skin problemsdermatitisobj15-17

• 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

79

• 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

80

• 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

81

• 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

82

• 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

83

• 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 10th edit. For s/e to
  corticosteroids

84

• 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

85

• 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

86
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

87

• 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

88

• 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

89

• 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.

90

• Anthralin, a strong irritant, may be used with
  salicylic acid as a paste.
• Can cause a chemical burn, not on for gt2h
• 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

91

• 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

92

• 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

93

• 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

94

• 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

95

• Usually females pred. In males, often have
  Rhinophyma (enlarged, redenned/purplish nose
• Heat/cold, spicey foods
• Avoid temp. extremes/alcohol/stress

96
(No Transcript)
97
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

98
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.

99

• 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

100
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

101
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

102
HERPES SIMPLEXcommon 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

103

• Lies dormant in nerve ganglia near the spinal
  cordimmune system cant 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

104

• 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

105

• 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

106

• 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

107

• 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

108
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

109

• 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

110

• Furuncles can progress to carbuncles
• Systemic infection
• Can spread infection to others (staph)
• Scarring can occur, may require ID, and systemic
  antibiotics

111

• DO NOT SQUEEZE AND IRRITATE
• Use antibacterial soaps to cleanse/ointment
• Surg. Id
• 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

112
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

113

• 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

114

• 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

115

• 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

116

• 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

117
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

118
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
• Doesnt 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

119

• Only reliable way to differentiate from HSV is
  culture, serum PCR/IFA
• Use of new vaccine, Zostavax in people age 60 and
  younger

120
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

121

• 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

122

• 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

123

• Pt teaching important
• Feet dry, avoid plastic/rubbersoled shoes
• Water shoes in public showers
• Cotton socks to absorb perspiration

124

• 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

125

• 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

126

• 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

127

• 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

128

• 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

129

• 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

130

• Topicals usually not effective
• May need nail avulsion (removal)
• High rate of relapse

131
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

132

• Presents with warmth, pain, edema, erythema,
  tenderness, fever locally and progresses
  rapidlyif not treated
• CS of pustule or lesions to identify organism.
  May need blood cultures if bacteremia suspected
• Always be aware of your patients immune status

133

• 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

134
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

135

• 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

136

• 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

137

• 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

138
Parasitic disordersinfestations

• 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

139

• 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

140

• 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

141

• Prevent by avoiding contact with infested
  persons/objects
• Dont share equip.,routine washing of clothing

142

• 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

143

• 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

144

• Rid, A-200 pyrinate must be re-applied in one
  week
• Physostigmine opthal. Oint to eyebrows, lashes,
  no other meds

145

• 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

146
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

147

• 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

148

• 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

149

• 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

150

• 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

151
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

152

• 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

153

• Dx by Nikolskis sign (sloughing or blistering
  of nl skin when pressure applied)
• Bx will reveal acantholysis (separation of
  epidermal cells from each other

154

• 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

155
Nursing care

• Educate pt on effects and side effects of
  medications
• Maintain IO, body wt, b/p
• Potassium permanganate baths to cleanse,
  disinfect and remove odors. Thoroughly dissolve
  these crystals
• Offer fluids, provide appropriate psycho-social
  support

156

• 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

157
BURNSpages967-976 278-288 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

158

• 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

159

• 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

160

• 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

161

• 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

162

• 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

163

• GI problems ie. Gastric dilation, Curlings 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)

164

• 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.

165

• 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

166
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

167

• MINOR BURNS
• 15 of TBSA NOT involving face , hands, genitalia
  or
• Full thickness burn less than 2 of TBSA

168

• 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

169

• MODERATE BURNS
• 15-25 of TBSA or
• Full thickness burns that are 10 of TBSA

170

• 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

171

• 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

172
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

173
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(bodys ability to extract O2 from lungs)

174
Emergent phaseonset 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

175

• DO NOT APPLY ICE
• Assist in wound debridement/medicate for pain
  prior to txs

176

• Assess for hypovolemia (decreased B/P, incr. HR,
  and respirations)
• Monitor ABGs, and carboxyhemoglobin levels

177

• Initiate intravenous access, USUALLY LACTATED
  Ringers, 0.9 saline or plasma
• Possible need for TPN
• Monitor v/s CLOSE, ACCURATE IO
• Maintain NPO
• Insert indwelling catheter
• Administer pain medication as prescribed
• Administer Tetanus toxoid as prescribed
• Monitor extr for any circumferential burns

178

• 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

179

• Patients, especially children, may quickly become
  hypervolemic (within 24-96h) even to having
  pulmonary edema

180

• Sterile technique/hand washing
• Prevent infection/sepsis

181
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

182

• Dialy wound cleansing and debridement
• MEDICATE FOR PAIN
• Hubbard tank or showering for cleansing
• Debridement mech. Chemical, surgical or
  combination

183
Dressings

• Open or closed, biologic or synthetic or combo
• Open involves topical agent no dressing
• Closed involves occlusive drsg over the wound

184

• 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

185
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

186

• 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

187

• 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

188
SKIN GRAFTING

• Autograft is skin graft from the PATIENTS
  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

189

• 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

190

• Disadvantages include
• Prone to chronic breakdown
• More likely to hypertrophy
• More likely to contract

191

• 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

192

• 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

193
Promoting factors

• Adequate hemostasis
• Anatomic location of graft
• S