Nutritional Support for Burn Patients

Integumentary System

• This system encompasses the skin and its associated structures.
• Key structures include the epidermis and dermis.
• The epidermis is stratified squamous epithelial tissue; it lacks blood vessels.
• Nutrients diffuse into the epidermis from the dermis.
• The dermis contains collagen, elastin, and reticular fibers, contributing to skin strength and elasticity.
• Blood vessels, sweat glands, and sebaceous glands reside within the dermis.
• Hair follicles are embedded in the dermis.
• The hypodermis, or subcutaneous tissue, lies beneath the dermis.
• This layer contains loose connective tissue and fat, providing insulation and cushioning.
• Structures like hairs, glands, and nerve endings originate and terminate within the dermis.

Review of Anatomy & Physiology

• Epidermis is the outermost layer, made of stratified squamous epithelial tissue.
• The dermis is the inner layer consisting primarily of connective tissues and elastic fibers.
• The hypodermis is the deepest layer, composed of loose connective tissue and adipose (fat) tissue.

Hair

• The hair shaft protrudes above the skin.
• The hair follicle encloses the hair root.
• Hair follicles extend into the dermis.
• The papilla nourishes each hair.
• The arrector pili muscle raises hairs when cold or frightened.

Glands

• Eccrine glands are distributed across the body, producing sweat.
• Apocrine glands, limited to axillae and anogenital areas, become active at puberty.
• Sebaceous glands secrete sebum to lubricate skin and hair.

Effects of Aging

• Hair follicles become inactive and melanocytes die, leading to gray and thinning hair.
• Epidermal cell division slows, making skin thinner and more fragile.
• Collagen and elastin fibers deteriorate causing wrinkles.
• Fat in subcutaneous layer decreases.
• Sebaceous and sweat glands become less active, resulting in dry and itchy skin.
• Temperature regulation becomes harder.

Physical Assessment

• Inspection and palpation are essential to assess skin.
• Skin turgor, color, lesions, moisture, and edema measurements are vital aspects to assess.
• Also evaluate vascular lesions like petechiae and ecchymosis, and the integrity and cleanliness of skin.

Skin Lesions (Primary & Secondary)

• Primary lesions represent initial changes in skin color, texture, or elevation, and their classification includes macules, papules, nodules, vesicles, bullae, pustules, wheals, and plaques.
• Secondary lesions arise from the evolution or alteration of primary lesions, including crusts, scales, fissures, ulcerations, excoriations, and scars.

Diagnostic Tests

• Diagnostic tests include culture, biopsy (punch, shave, or incisional), wood light examination, and allergy skin testing.

Therapeutic Measures

• Common topical and systemic measures used to treat integumentary conditions include: wet dressings, balneotherapy, colloidal baths, medicated tar baths, bath oils, topical corticosteroids, intralesional therapy, dry dressings, occlusives, plastic wrap, hydrocolloid dressings, gels, and pastes.

Dermatitis

• Contact dermatitis: acute or chronic condition resulting from contact with irritants.
• Atopic dermatitis: chronic, inherited skin condition often associated with respiratory allergies or asthma.
• Seborrheic dermatitis: inflammatory condition involving excessive sebum production, commonly seen in infants and adults.

Psoriasis

• A chronic inflammatory skin disorder with epidermal cells proliferating rapidly
• Characterized by exacerbations and remissions
• Triggered by autoimmune responses and environmental factors.
• Presents with skin lesions, plaques, and silvery scales.
• Associated complications include infection and joint inflammation.

Risk Factors For Psoriasis

• Overexposure to ultraviolet rays, fair skin, and family history are known risk factors.
• Infection, stress, hormone changes, cold weather, skin trauma, and medications such as lithium or beta-blockers are other contributing factors.
• Obesity might also be considered.

Medications for Psoriasis

• Topical corticosteroids, tar preparations, vitamin D analogs, vitamin A (avoid during pregnancy), systemic medications (for severe cases), cytotoxic medications, and biologic agents (immunosuppressants) are used to treat psoriasis.

Scleroderma

• Systemic sclerosis that affects many organs
• Characterized by skin hardening and fibrosis.

Herpes Simplex Virus (HSV)

• HSV Type 1 typically causes oral herpes, while HSV Type 2 usually creates genital herpes.
• Transmission occurs through direct or fluid exposure.
• The virus remains dormant until triggered by stressors.
• Treatment generally consists of antiviral agents.

Herpes Zoster (Shingles)

• A reactivation of the varicella-zoster virus, the same virus that causes chickenpox.
• Presents with painful vesicles in a dermatomal pattern.
• Affects individuals with weakened immune systems.
• Usually a self-limiting affliction, but can lead to post-herpetic neuralgia and other complications.

Cellulitis

• Inflammation of the skin and subcutaneous tissue, often caused by bacterial infections (e.g., MRSA)
• Manifests as warmth, redness, edema, pain, and tenderness.
• Diagnosis often relies on culture and sensitivity tests.
• Treatment generally involves topical and systemic antibiotics.

Fungal Infections

• Infections frequently include tinea pedis (athlete's foot), tinea capitis (scalp ringworm), tinea corporis (body ringworm), tinea cruris (groin ringworm), tinea unguium (nail fungus), and candidiasis (thrush).

Acne Vulgaris

• A prevalent skin condition characterized by inflammation and comedones (blackheads and whiteheads) of the sebaceous glands and hair follicles.
• Associated with hormonal fluctuations, especially during puberty.
• Often treated with topical and oral medications.

Parasitic Skin Disorders

• These disorders are caused by parasites, such as lice (pediculosis) and mites (scabies).
• Lice can be present on the scalp, pubic region, and body.
• Scabies causes skin rashes and intense itching from mite infestations.

Benign Skin Lesions

• Benign skin lesions include seborrheic keratosis, keloids, nevus (moles), warts, cysts, and hemangiomas (blood vessel tumors).

Malignant Skin Lesions

• A diverse group of cancerous skin lesions including basal cell carcinoma, squamous cell carcinoma, and malignant melanoma, which must often be differentiated.
• Skin cancer risk factors include overexposure to UV radiation, fair skin, multiple moles, family history, exposure to chemical agents, and immunosuppressive therapy.

Other Risk Factors

• Environmental pollutants, viral illnesses, severe burns, chronic skin irritations, and genetic predisposition can also increase the risk of specific integumentary issues.

Malignant Skin Lesions (Classifications)

• Basal cell carcinoma, squamous cell carcinoma, malignant melanoma (subtypes: lentigo maligna, superficial spreading, and nodular)

Kaposi's Sarcoma

• A cancer resulting from abnormal blood vessels, commonly presenting as purplish skin lesions.

Prevention for Malignant Skin Lesions

• To prevent malignant skin cancers, avoid excessive UV exposure, use sunscreen, wear protective clothing, and report suspicious changes in skin moles to a medical professional.

Diagnostic Tests & Other Cancers

• Biopsies of lesions or tumors, CA 125 test, alpha-fetoprotein, beta human chorionic gonadotropin, lactate dehydrogenase, and aminotransferase are employed to aid in diagnostic evaluations.

Therapeutic Measures

• Treatments include Mohs surgery, skin grafting techniques (autografts, artificial, and cultured epithelium), chemotherapy, radiation therapy, cryosurgery, curettage, electrodesiccation, and others.

Burns

• Burns are wounds resulting from heat, chemical, electrical, or radiation energy transfer.
• The severity depends on the agent's temperature, exposure duration, tissue conductivity, and skin thickness.
• Burns affect multiple physiological functions; therefore, managing the burn wound and associated systemic imbalances are paramount.
• The extent of burn injury is often quantified using the "rule of nines."
• Depending on the burn depth, treatments may include wound debridement, hydrotherapy, dressings, and possibly grafting.

Stages of Wound Healing

• The progression of wound healing typically involves four stages: hemostasis, inflammation, proliferation, and remodeling.
• Primary and secondary intention healing describe how the body closes wounds.

Nursing Care for Burns

• Key aspects of burn care include managing the respiratory and cardiovascular systems, fluid replacement, pain management, thermoregulation, gastrointestinal support, urinary management, and preventing infection.
• Nutritional support and restoration of mobility are crucial to the patient's recovery.

Psychosocial Effects of Burns

• Age, location of injury, extent of injury, and patient's pre-injury psychosocial state are significant factors in the patient's ability to adjust to their condition.
• Nurses should consider the patients' psychosocial needs, and refer to appropriate professional resources for support and guidance.

Pressure Injuries

• Pressure injuries can arise from prolonged pressure, friction, and shearing forces.
• Risk factors include immobility, impaired circulation, impaired sensory perception.
• Stages of pressure injuries, from stage 1 to deep tissue injury to unstageable, reflect the level of tissue damage.
• Prevention focuses on avoiding pressure and friction, as well as promoting good skin hygiene and mobility.
• Treatment might include pressure relieving surfaces or devices; dressings; and surgical interventions.

Therapeutic Procedures for Pressure Injuries

• Wound cleansing and debridement are crucial for patient care. Different types of dressings (hydrogel, polyurethane film, hydrocolloids, biologics, alginates, gauze, and other materials) are suited for various circumstances.
• Some instances involve the use of negative pressure wound therapy, employing devices to remove fluids and promote healing.

Classification of Burns

• Burns are categorized as superficial, partial thickness (first or second degree), or full thickness (third or fourth degree) based on the depth of skin damage.

Negative Pressure Wound Therapy

• A method for wound healing that employs negative pressure to remove fluids. The process assists in wound healing by keeping tissues moist and promoting cellular regeneration.