Integumentary Disorders and Management 2023 PDF

College of Applied Medical Sciences ADULT HEALTH NURSING-2 (NUR351) ADULT HEALTH NURSING-2 Integumentary Disorders and Management INTEGUMENTARY SYSTEM Anatomy and Physiology of Integument System ‫نتيجة بحث الصور عن‬ integumentary system picture The skin consist...

College of Applied Medical Sciences ADULT HEALTH NURSING-2 (NUR351) ADULT HEALTH NURSING-2 Integumentary Disorders and Management INTEGUMENTARY SYSTEM Anatomy and Physiology of Integument System ‫نتيجة بحث الصور عن‬ integumentary system picture The skin consists of two layers, the epidermis and the underlying dermis. Although technically not part of the skin, the hypodermis (subcutaneous layer, or superficial fascia) lies beneath the dermis. The Epidermis: The epidermis consists of stratified squamous epithelium. The Dermis: The second layer of the skin, the dermis, consists of various connective tissues. The Hypodermis: The hypodermis (subcutaneous layer or superficial fascia) lies between the dermis and underlying tissues and organs.  The skin performs a variety of functions: Protection is provided against biological invasion, physical damage, and ultraviolet radiation. Sensation for touch, pain, and heat is provided by nerve endings. Thermoregulation is supported through the sweating and regulation of blood flow through the skin. Metabolism of vitamin D occurs in the skin. Excretion of salts and small amounts of wastes occurs with the production of sweat. ‫صورة ذات صلة‬ Herpes Simplex Herpes Simplex is a very common skin infection ‫الصور عن‬simplex herpes ‫نتيجة بحث‬  Types: Type I occurs in mouth Type II occurs in genital area But both types can be found in both locations ‫الصور عن‬ types herpes ‫ بحث‬simplex ‫نتيجة‬ ‫‪simplex‬الصور عن‬ ‫‪herpes‬‬ ‫نتيجة بحث‬  Orolabial Herpes ‫الصور عن‬ types herpes ‫ بحث‬simplex ‫نتيجة‬ Orolabial herpes, also called fever blisters or cold sores, consists of erythematous-based clusters of grouped vesicles on the lips. A prodrome of tingling or burring, with pain, may precede the appearance of the vesicles by up to 24 hours. - HSV-1 is mainly transmitted by oral-to-oral contact, causing oral herpes.  Genital Herpes ‫صورة ذات صلة‬ Genital Herpes o Genital Herpes, type II, presents with a board spectrum of clinical signs. o Lesions appear as grouped vesicles on an erythematous base initially involving the vagina, rectum, or penis. o HSV-2 is a sexually transmitted infection that causes genital herpes.  Genital Herpes o New lesions can continue to appear for 7 to 14 days. o Lesions are symmetric and usually cause regional lymphadenopathy. o Fever and flulike symptoms are common. o Typical recurrences begin with a prodrome of burning, tingling, or itching about 24 hours before the vesicles appear. o As the vesicles rupture, erosions and ulcerations begin to appear. o Sever infections can cause extensive erosions of the vaginal or anal canal.  Complications of Herpes Simplex: 1- Eczema herpticum: is a condition in which patients with eczema (is an inflammatory skin condition) contract herpes that spreads throughout the eczematous areas. ‫الصور عن‬herpticum Eczema ‫نتيجة بحث‬ 2- Herpes whitlow: is an infection of the pulp of a fingertip with herpes type I or II. 3- Neonatal infection ‫الصور عن‬Neonatal herpes ‫نتيجة بحث‬ infection  Management of Herpes Simplex: An antiviral cream or ointment can relieve the burning, itching, or tingling. An antiviral medicine that is oral (pills) or intravenous (shot) can shorten an outbreak of herpes. Prescription antiviral medicines approved for the treatment of both types of herpes simplex include: o Acyclovir o Famciclovir o Valacyclovir  ‫‪Burn‬‬ ‫نتيجة بحث الصور عن‬ ‫‪burn‬‬  Introduction: ▪ Burn is one of the most painful injuries that one can ever experience. ▪ When a burn occurs to the skin, nerve endings are damaged causing intense feelings of pain. ▪ Serious burns are complex injuries. In addition to the burn injury itself, a number of other functions may be affected. Burn injuries can affect muscles, bones, nerves, and blood vessels.  Introduction: ▪ The respiratory system can be damaged, with possible airway obstruction, respiratory failure and respiratory arrest. ▪ Since burns injure the skin, they impair the body's normal fluid/electrolyte balance, body temperature, body thermal regulation, joint function, manual dexterity, and physical appearance. Introduction: ▪ In addition to the physical damage caused by burns, patients also may suffer emotional and psychological problems that begin at the emergency scene and could last a long time.  Causes: Thermal - including flame, or excessive heat from fire, steam, and hot liquids and hot objects. Chemical - including various acids, bases, and caustics. Electrical - including electrical current and lightning. Radiation - such as from nuclear sources. Ultraviolet light is also a source of radiation burns.  Prevention of Burn: Keep all matches out of reach of children Never leave children unattended around fire or bathroom/ bathtub. Install and maintain smoke detectors in the home. Develop and practice a home exit fire drill with all members of household.  Prevention of Burn: Set the water heater temperature no higher than 120 F. Do not smoke in bed. Do not fall asleep while smoking. Do not throw flammable liquids onto an already burning fire.  Prevention of Burn: Watch for overhead electrical wires and underground wires when working outside. Never store flammable liquids near a fire source. Use caution when cooking. Keep a working fire extinguisher in your home. Pathophysiology of Burns: Burns are caused by a transfer of energy from a heat source to the body. Burns are categorized as thermal, electrical, radiation, or chemical. Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source. Pathophysiology of Burns: Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image. Pathophysiology of Burns: The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. Temperatures less than 111°F are tolerated for long periods without injury. Classification of Burns: A newer classification of "Superficial Thickness", "Partial Thickness" (which is divided into superficial and deep categories) and "Full Thickness" relates more precisely to the epidermis, dermis and subcutaneous layers of skin and is used to guide treatment and predict outcome.  A description of the traditional and current classifications of burns. Traditional Nomenclature Depth Clinical findings nomenclature Epidermis Erythema, minor Superficial thickness First-degree involvement pain, lack of blisters Partial thickness — Superficial (papillary) Blisters, clear fluid, Second-degree superficial dermis and pain Whiter appearance, with decreased pain. Partial thickness — Deep (reticular) Second-degree Difficult to deep dermis distinguish from full thickness Dermis and Hard, leather-like Third- or fourth- underlying tissue and Full thickness eschar, no sensation degree possibly fascia, bone, (insensate) or muscle Assessing burns: A- Rule of nines: Burns are assessed in terms of total body surface area (TBSA), which is the percentage affected by partial thickness or full thickness burns (superficial thickness burns are not counted). The rule of nines is used as a quick and useful way to estimate the affected TBSA.  Rule of nines for assessment of total body surface area affected by a burn 1. Adult Anatomic structure Surface area Head 9% Anterior Torso 18% Posterior Torso 18% Each Leg 18% Each Arm 9% Perineum 1% Rule of Nines in adult 2. Infant Anatomic structure Surface area Head 18% Anterior Torso 18% Posterior Torso 18% Each Leg 14% Each Arm 9% Perineum 1%  Assessing burns: B- Lund and Browder Method: A more precise method of estimating the extent of a burn, which recognizes the percentage of BSA of various anatomic parts, especially the head and legs, changes with growth. By dividing the body into very small areas and providing an estimate of the proportion of BSA accounted for such body parts, one can obtain a reliable estimate of the total BSA burned. Assessing burns: C- Palm Method: In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of patient's palm is approximately 1% of BSA. The size of the palm can be used to assess the extent of burn injury. Management of the patient with a burn injury: Phases of burn care: Phase Duration Priorities 1- Emergent or - From onset of injury to completion of - First aid immediate fluid resuscitation - Prevention of shock Resuscitative - Prevention of respiratory distress - Detection and treatment of concomitant injuries - Wound Assessment and initial care * Wound care and closure * Prevention or treatment of complications, including infection. 2- Acute - From beginning of diuresis to near * Nutritional Support completion of wound closure - Prevention of scars and contractures. - Physical, occupational, and vocational rehabilitation. - Functional and cosmetic - From major wound closure to return reconstruction 3- Rehabilitation to individual’s optimal level of physical - Psychosocial counseling. and psychological adjustment A- Emergent / Resuscitative phase of burn care: On -the – Scene Care: Severe Burns DO NOT overcool the casualty; this may dangerously lower the body temperature. DO NOT remove anything sticking to the burn; this may cause further damage and cause infection. DO NOT touch or interfere with the injured area. DO NOT burst blisters. DO NOT apply lotions, or fat to the injury. A- Emergent / Resuscitative phase of burn care: Lay the casualty down, protecting the burned area from contact with the ground, if possible. Douse the burn with copious amounts of cold liquid. Thorough cooling may take 10 minutes or more, but this must not delay the casualty’s transmission to hospital. While cooling the burns, check airway, breathing, and pulse, and be prepared to resuscitate. A- Emergent / Resuscitative phase of burn care: Gently remove any rings, watches, belts, shoes, or smouldering clothing from the injured area, before it starts to swell. Carefully remove burned clothing unless it is sticking to the burn. Cover the injury with a sterile burns sheet or other suitable non-fluffy material, to protect from infection. Burns to the face should be cooled with water, not covered. A- Emergent / Resuscitative phase of burn care: Ensure that the emergency service is on its way. While waiting, treat the casualty for shock. Monitor and record breathing and pulse, and resuscitate, if necessary.  Burns to the Mouth and Throat: ▪ Burns to the face and burns in the mouth or throat are very dangerous, as they cause rapid swelling and inflammation of the air passages. ▪ The swelling will rapidly block the airway, giving rise to a serious risk of suffocation. ▪ Immediate and highly specialised medical assistance is required. Treatment of Burns to the Mouth and Throat: ▪ Contact the emergency service. Report suspected burns to the airway. ▪ Take any steps to improve the casualty’s air supply, e.g., loosening clothing around the neck. Give the casualty oxygen if you are trained to do so. ▪ If the casualty becomes unconscious, place in the recovery position, and be prepared to resuscitate.  Emergency Medical Management: Initial priorities in the emergency department remain airway, breathing, and circulation. All clothing and jewelry are removed Flushing of chemical burn with water The patient is checked for contact lenses and removed immediately, if burn is in the face.  Emergency Medical Management: Obtain history of preexisting diseases, allergies, and medications and the use of drugs, alcohol, and tobacco. A large –bore (16-0r 18-gauge) Intravenous catheter should be inserted in a non burned area. If the patient's burn exceeds 25% BSA or if the patient is nauseated, a nasogastric tube should be inserted and connected to suction to prevent paralytic ileus (absence of peristalsis).  Emergency Medical Management: Assessing the burn, nonsterile gloves, caps, and gowns are worn while assessing the exposed burned areas. Insert an indwelling urinary catheter. Baseline height, weight, arterial blood gases, hematocrit, electrolyte values, urine analysis, and chest x-ray are obtained. ECG is obtained when patient has electrical burn.  Transfer to a Burn Center: If the patient is to be transported to a burn center, the following measures are instituted before transfer: A secure intravenous line is placed, with fluid infusing at the rate required to attain urine output at least 30 mL/hour. A patent airway is ensured.  Transfer to a Burn Center: Adequate pain relief is attained. Adequate peripheral circulation is established in any burned extremity. Wounds are covered with a clean, dry sheet, and the patient is kept comfortably warm.  Management of Fluid loss and Shock: Fluid Replacement: The projected fluid requirements for the first 24 hours are calculated by the physician based on the extent of the burn injury. Some combination of fluid categories may be used: colloids (as whole blood) and crystalloids/ electrolytes (as lactated Ringer's solution).  Management of Fluid loss and Shock: Fluid Replacement: Adequate fluid resuscitations result in slightly decreased blood volume levels during the first 24 post burn hours and restores plasma levels to normal by the end of 48 hours.  Management of Fluid loss and Shock: Fluid Replacement: Formulas have been developed for estimating fluid loss based on the estimated percentage of burned BSA and the weight of the patient. The consensus formula provides for the volume of balanced salt solution to be administered in the first 24 hours by using this form: 2 mL / kg / % BSA  Management of Fluid loss and Shock: Fluid Replacement: Example: Calculate the amount of fluid needed for 70-kg patient with a 50% BSA burn: Using Consensus formula: 2 mL / kg / % BSA 2 x 70 x 50 = 7000 mL /24 hours Management of Fluid loss and Shock: Fluid Replacement: Half of the calculated total should be given over the first 8 postburn hours, and the other half should be given over the next 16 hours. Management of Fluid loss and Shock: Fluid Replacement: Goals of Fluid Replacement Therapy: ✓ Systolic blood pressure exceeding 100 mmHg ✓ Pulse rate less than 110/ minute ✓ Urine output of 30 to 50 mL/ hour B- Acute or Intermediate Phase of Burn Care: The acute or intermediate phase of burn care follow the emergent/resuscitative phase and begins 48 to 72 hours after burn injury. B- Acute or Intermediate Phase of Burn Care: During this phase attention is directed toward: Continued assessment and maintenance of respiratory and circulatory status Fluid and electrolyte balance Gastrointestinal function Infection prevention Burn wound care Pain management Nutritional support B- Acute or Intermediate Phase of Burn Care: 1- Infection Prevention: Despite aseptic precautions and the use of topical antimicrobial agents, the burn wound is an excellent medium for bacterial growth and proliferation. The burn eschar is nonviable crust with no blood supply; therefore, neither polymorphonuclear leukocytes or antibodies nor systemic antibiotics can reach the area. B- Acute or Intermediate Phase of Burn Care: Measures to prevent bacterial infection are: Cap, gown, mask, and gloves are worn while caring for the patient with open burn wounds. Tissue specimen (swab, or tissue biopsy cultures) are taken for culture regularly to monitor colonization of the wound by microbial organisms. Systemic antibiotics are administered when there is burn wound sepsis, or other positive cultures such as urine, sputum, or blood. B- Acute or Intermediate Phase of Burn Care: 2- Wound Cleaning: Hydrotherapy: In the form of shower carts, individual showers, and bed baths can be used to clean the wounds. During the bath, the patient is encouraged to be as active as possible. Hydrotherapy provides a excellent opportunity for exercising the extremities and cleaning the entire body. B- Acute or Intermediate Phase of Burn Care: 2- Wound Cleaning: Hydrotherapy: When the patient is removed from the tub after the bath, any residue adhering to the body is washed away with a clear water spray or shower. At the time of wound cleaning, all skin is inspected for any hints of redness, breakdown, or local infection. Hair in and around the burn area, except the eyebrows, should be clipped short. B- Acute or Intermediate Phase of Burn Care: 2- Wound Cleaning: Hydrotherapy: Intact blisters may be left, but the fluid should be aspirated with a needle and syringe and discarded. Wound cleaning is usually performed at least daily. After the burn wound are cleaned, they are gently patted with towels and wound care is performed. B- Acute or Intermediate Phase of Burn Care: 2- Wound Cleaning: Topical Antibacterial Therapy: - The best method of local care in extensive burn injury, is the application of topical antimicrobial therapy to wound care to reduce the number of bacteria. Three most commonly used topical agents are: Silver sulfadiazine (Silvadene) Silver nitrate Mafenide acetate (Sulfamylon) B- Acute or Intermediate Phase of Burn Care: Wound dressing: When the wound is clean, the burned areas are patted dry, and the prescribed topical agent is applied; the wound is then covered with several layers of dressings. A light dressing is applied over the joints area to allow for motion. If the hand or foot is burned, the fingers and toes should be wrapped individually to promote adequate healing. B- Acute or Intermediate Phase of Burn Care: Exposure Method: A wound is treated by exposing it to air. Wound care proceeds in the described manner and a topical agent is applied, but no dressing is applied. The success of exposure method depends on keeping the immediate environment free of organisms. Everything coming in contact with the patient is sterile. B- Acute or Intermediate Phase of Burn Care: Exposure Method: Those who come in direct contact with the patient wear masks, caps, sterile gowns, and gloves. Visitors are instructed to wear protective grab and not to touch the bed or hand the patient anything. The patient's room must be maintained warm. B- Acute or Intermediate Phase of Burn Care: Exposure Method: A cradle may be placed over the patient to prevent sheets from coming in contact with the burn area, to minimize the effects of air currents, and to provide some covering. Small areas such as the face, neck, or perineum may be effectively treated with the exposure method, while other areas of the wound may dress. B- Acute or Intermediate Phase of Burn Care: Occlusive Method: Theses dressing are applied under sterile conditions in the operating room. These dressings remain in place for 3 to 5 days, at which time they are removed by the physician for examination of the graft. B- Acute or Intermediate Phase of Burn Care: Dressing Changes: Dressings are changed in the patient's unit, hydrotherapy room, or treatment area approximately 20 minutes after an analgesic is administered. They may be also be changed in the operating room after the patient is anesthetized. A mask, hair cover, disposable plastic apron or cover gown, and gloves are worn by health care personnel when removing the dressings. B- Acute or Intermediate Phase of Burn Care: Dressing Changes: The outer dressings are slit with blunt scissors, and the soiled dressings are removed and disposed of in accordance with established procedures for contaminated materials Dressings that adheres to the wound can be removed more comfortably if they are moistened with saline solution or if the patient is allowed to soak for a few moments in the tub. B- Acute or Intermediate Phase of Burn Care: Dressing Changes: The remaining dressings are carefully and gently removed with forceps or gloved hands. Sterile scissors and forceps may be used to trim loose eschar and encourage separation of devitalized skin. The color, odor, size, exudates, signs of reepithelization, and other characteristics of the wound and the eschar and any changes from the previous dressing change are noted. B- Acute or Intermediate Phase of Burn Care: Types Wound Debridement: 1- Natural Debridement: With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. B- Acute or Intermediate Phase of Burn Care: Types Wound Debridement: 2- Mechanical Debridement: It involves using surgical scissors and forceps to separate and remove the eschar. This technique can be performed by skilled physicians, nurses, or physical therapists and is usually done with daily dressing changes and wound cleaning procedures. B- Acute or Intermediate Phase of Burn Care: Types Wound Debridement: 3- Surgical Debridement: It is an operative procedure involving either primary excision of the full thickness of the skin down to the fascia or shaving the burned skin layers gradually down to freely bleeding, viable tissue. Grafting the Burn Wound: If the wounds are deep (full-thickness) or extensive, spontaneous reepithelialization is not possible. Therefore, coverage of the burn wound is necessary until coverage with a graft of the patient's own skin (autograft) is possible.  Grafting the Burn Wound: Care of the patient with an Autograft: Occlusive dressings are commonly used initially after grafting to immobilize the graft. The graft may be left open with skin staples to immobilize it, which allows close observation of progress. The first dressing change is usually performed by the surgeon 3 to 5 days after surgery, or earlier in case of purulent drainage or a foul odor.  Grafting the Burn Wound: Care of Donor Site: A moist gauze dressing is applied at the time of surgery to maintain pressure and to stop any oozing. A thrombostatic agent such as thrombin or epinephrine may be applied directly to the site as well.  Grafting the Burn Wound: Care of Donor Site: The donor site must remain clean, dry, and free from pressure. Ultimately, because a donor site is usually a partial-thickness wound, it will heal spontaneously within 7 to 14 days with proper care; however, the donor site is often painful. 3- Pain Management: Minimize the pain with analgesics before the patient faces wound care procedures. Adequate staff working gently, swiftly, and skillfully, the duration of pain from wound care can be shortened. Bolus doses of opioids, usually morphine, are often provided. 3- Pain Management: Ketamine anesthesia administered intravenously is also used for some wound care procedures in burn unit. Patient-controlled analgesia, using both continuous and bolus morphine infusions, and sustained-release oral morphine, given every 12 hours with an additional dose before wound care, have helped burn patients. Disorders of Wound Healing: 1- Scars: Hypertrophic scars and wound contractures are more likely to occur if the initial burn injury extends below the level of the deep dermis. Disorders of Wound Healing: 2- Keloids: A large, heaped-up mass of scar tissue, a keloid, may develop and extend beyond the wound surface. Keloids tend to be found in darkly pigmented people, tend to grow outside of wound margins, and are more likely to recur after surgical excision. Disorders of Wound Healing: 3- Failure to heal: Failure of the wound to heal may relate to many factors, including infection and inadequate nutrition. A serum albumin level of less than 2g/dL is usually a factor in impaired healing in the burn patient. Disorders of Wound Healing: 4- Contracture: The burn wound tissue shortens. Any opposing force provided by splints, traction, and purposeful movement and positioning must be used to counteract deformity in burns affecting joints.  C- Rehabilitation Phase of Burn Care: Rehabilitation begins immediately after the burn has occurred- as early as the emergent period and often extends for years after injury. Wound healing, psychological support, and restoring maximal functional activity remain priorities. The focus on maintaining fluid and electrolyte balance and improving nutritional status continues.  Prevention of Hypertrophic Scarring: The wound is in a dynamic state for 1.5 to 2 years after the burn occurs. Healed areas that are prone to hypertrophic scarring require the patient to wear a pressure garment.  Prevention of Hypertrophic Scarring: These devices are especially useful for partial-thickness wounds that required more than 2 weeks to heal and for the edges of grafted skin. The physical therapist, occupational therapist, or representative of the manufacturer of elastic pressure garments measures the patient for correct fit.  Prevention of Hypertrophic Scarring: Patients must be instructed about the need for lubrication and protection of the healing skin and the need for pressure garments for at least a year after injury. A program including elastic pressure garments, splints, and exercise under the supervision of an experienced physical and occupational therapy team is recommended for optimal functional and cosmetic result.  C- Rehabilitation Phase of Burn Care: Reconstructive surgery to improve body appearance and function may be needed. Psychological and vocational counseling and referral to support groups may be helpful to promote recovery and quality of life. Family members also need support and guidance in assisting the patient to return to optimal health.