Care of Patients With Integumentary Disorders & Burns PDF

43: Care of Patients With Integumentary Disorders and Burns Inflammatory Infections Many skin diseases result from infection with bacteria, viruses, or fungi or from infestation with parasites. Diseases of this kind require special precautions to prevent spread of the infectious organism or the par...

43: Care of Patients With Integumentary Disorders and Burns Inflammatory Infections Many skin diseases result from infection with bacteria, viruses, or fungi or from infestation with parasites. Diseases of this kind require special precautions to prevent spread of the infectious organism or the parasite. Hand hygiene is a first-line measure in the prevention of health care– associated infections and is mandated as one of The Joint Commission’s National Patient Safety Goals. Infectious Disease National Centers, a division of the Centers for Disease Control and Prevention (CDC), recommends that contact precautions, as well as Standard Precautions, be implemented for a number of these diseases (Box 43.1). Some skin infections are not necessarily contagious; however, it can be difficult to quickly determine whether a condition is a contagious type at the initial examination. Therefore isolate the patient, perform hand hygiene, and use Standard Precautions (see Appendix B) if there is any doubt. Box 43.1 Review of Contact Precautions Specifications for contact precautions are as follows: A private room is indicated. In general, patients infected with the same type of organism may share a room. Gloves are worn when entering the room. Change gloves after contact with infective material, such as wound drainage or feces, and before treating a different location on the body. Perform hand hygiene before donning clean gloves. Remove gloves when leaving the room and perform hand hygiene using an antimicrobial agent. Gowns are indicated if soiling is likely, particularly if there is drainage from an uncovered wound or the patient is incontinent. Articles contaminated with infective material should be discarded in a biohazard waste receptacle or bagged and labeled before being sent for decontamination and reprocessing. Patient care equipment should be used only for the one patient and should be left in the room until no longer needed. Skin disorders that require contact precautions include: Furunculosis, group A Streptococcus Herpes simplex, disseminated, severe primary, or neonatal Herpes zoster (varicella zoster) disseminated also requires airborne precautions Impetigo Infection or colonization by bacteria with multiple drug resistance (any site) Pediculosis Scabies Skin wound or burn infection, major (draining and not covered by dressing, or dressing does not adequately contain purulent material), including those infected with Staphylococcus aureus Vaccinia (generalized and progressive eczema vaccinatum) Dermatitis Dermatitis is not contagious unless a secondary infection has occurred in the lesions. Etiology, Pathophysiology, Signs, and Symptoms Contact dermatitis is a delayed allergic response involving cell-mediated immunity. On contact with the skin, the allergen is bound to a carrier protein and forms a sensitizing antigen. T cells become sensitized to the antigen. Local skin irritation is evident within a few hours or days after exposure to an antigen. Erythema and swelling, pruritus, and the appearance of vesicular lesions follow. Many chemicals; cosmetics; soaps; latex; and poison ivy, oak, and sumac are contact irritants and can cause such a reaction. Atopic dermatitis (also called eczema) affects about 10% of the population and is more common in infancy and childhood but does affect some adults. It results from a complex activation process that involves mast cells, T lymphocytes, Langerhans cells, monocytes, B cells that produce immunoglobulin E, and other inflammatory cells that release histamine, lymphokines, and other inflammatory mediators. Atopic dermatitis does seem to have a genetic, allergic association because it is more prevalent in families. Stasis dermatitis generally occurs on the legs as a result of venous stasis and edema and is seen in conjunction with varicosities, phlebitis, and vascular trauma. Erythema and pruritus occur first, after which scaling, development of petechiae, and hyperpigmentation (excessive pigmentation) occur. Lesions may become ulcerated, particularly around the ankles and tibia. Seborrheic dermatitis is a common inflammation involving the scalp, eyebrows, eyelids, ear canals, nasolabial folds, axillae, chest, and back. It is most common on the scalp. The cause is unknown. Lesions appear as scaly white or yellowish plaques with mild pruritus. Diagnosis and Treatment Dermatitis is diagnosed by inspection and by compiling a complete history, looking for possible exposure to causative substances. In general, treatment is aimed at avoidance of the contact irritant or allergen, good skin lubrication, preservation of skin moisture, and control of inflammation and itching. Topical agents are often used. Corticosteroids may be used topically or sometimes orally or by injection to intervene in a severe episode of dermatitis. Nursing Management Teach patients to avoid contact irritants and to properly care for their skin. Instruct them in the proper way to apply topical agents. Caution any patient who is experiencing pruritus to avoid becoming hot, bathe in tepid water, and not puncture vesicles. The skin should be patted dry rather than rubbed dry. Acne Etiology, Pathophysiology, Signs, and Symptoms Acne is a disorder of the skin characterized by papules and pustules over the face, back, and shoulders. It can be classified as mild, moderate, or severe depending on the extent and type of lesions. Some types of acne are related to cosmetics or to chemicals in the environment. For example, occupational acne is caused by prolonged contact with oils and tars. There are many kinds of acne, but the two major types are acne rosacea and acne vulgaris. Acne rosacea usually begins between ages 30 and 50 years. It is characterized by erythema (redness), papules, pustules, and telangiectases (dilation of capillaries causing small red or purple clusters, also called “spider veins”). It occurs on the face over the cheeks and bridge of the nose. Comedos (dilated hair follicles filled with skin debris, bacteria, and sebum) do not occur. Factors that cause facial flushing precipitate worsening. Tea, coffee, alcohol (especially wine), caffeine-containing foods, spicy foods, sunlight, and emotional stress cause flare-ups. Acne vulgaris is more common than acne rosacea. Factors that contribute to the development of acne include hereditary disposition, increased androgen levels, and premenstrual hormonal fluctuations. Use of heavy creams, use of certain drugs, and exposure to increased heat also contribute to the disorder. Acne vulgaris typically begins in early puberty, continues through the teens, and then begins to subside. Occasionally it persists, or it can recur several years later. The onset of acne vulgaris in adolescents is related to increased release of sex hormones, which stimulate activity of the sebaceous glands, causing increased production of sebum. Ducts leading from the sebaceous glands become plugged with sebum. It is not known why in some persons the ducts from these glands become plugged, but the increased production of sebum triggers the formation of open comedos (blackheads) and closed comedos (whiteheads). The color of blackheads results from particles of melanin, the skin’s own pigment, combined with sebum and keratin. Accumulations of sebum, skin particles, and dead skin cells can cause an inflammatory reaction. Bacterial infection leads to the formation of pustules. An extensive inflammation can lead to the formation of cysts, with swelling above and below the surface of the skin. There are many misconceptions about acne vulgaris and its treatment. It is not a contagious disease. It is not caused by uncleanliness or poor personal hygiene. Diet can contribute to the formation of lesions, but generally there is little or no relationship between the intake of certain foods and the appearance of the lesions of acne. Typically, chocolate, colas, and fried foods do not need to be eliminated from the diet in an effort to prevent or cure acne. A well-balanced diet is all that is recommended in the management of acne. Diagnosis and Treatment Diagnosis is by history and physical examination. Acne rosacea is treated by avoiding the triggers for flare-ups, regularly using sunscreen, and using metronidazole (MetroGel) and retinoids. Sometimes topical and/or oral antibiotics are prescribed. Mild, noninflammatory cases of acne vulgaris respond well to retinoids, which are available over the counter and prescription strength. Nonprescription drugs, such as lotions, creams, and gels that contain sulfur, benzoyl peroxide, or sulfur combined with resorcinol usually are effective for noninflammatory acne. Among the topical medications, retinoic acid (tretinoin [Retin-A]) is the best agent for papular and pustular acne problems. It should be used once or twice a day. Benzoyl peroxide is the most commonly used topical agent for acne and is available both by prescription and over the counter. Azelaic acid (Azelex) is applied topically twice a day. The U.S. Food and Drug Administration (FDA) has approved Veltin Gel, a water-based topical agent, for the treatment of acne vulgaris in patients 12 years and older. It is a combination medication consisting of clindamycin phosphate and tretinoin gel (RxList, 2020). It is expensive, but financial assistance is available. Antibiotics such as tetracycline and erythromycin also are sometimes prescribed topically and orally for cystic acne to inhibit the growth of bacteria in the plugged ducts. Isotretinoin (13-cis-retinoic acid) has been especially effective in controlling cases of cystic acne that are resistant to other forms of treatment. The drug was initially marketed under the trade name Accutane, but after black box warnings and increasing numbers of reports of adverse events, including gastrointestinal concerns, birth defects, and increased rates of suicide, Roche discontinued marketing Accutane in the United States in 2009. It is still available in generic form and by other trade names (Mayo Clinic, 2020). Isotretinoin is taken by mouth daily for 2 to 4 months and inhibits activity of the sebaceous glands. Its effects are sustained for months to years after it has been discontinued. Almost all patients experience some adverse reaction to this drug. Isotretinoin is used only for severe cystic acne that is resistant to all other treatment. There are serious adverse side effects, including organ damage and mental problems. Laboratory testing includes hemoglobin, hematocrit, glucose, triglycerides, uric acid, alkaline phosphatase, and liver enzymes. For larger areas, lasers or a light treatment called photodynamic therapy has been used with success. A photosensitive solution is applied to the skin and remains until absorbed. Light is then applied, which activates the chemicals, destroying the target cells. Photodynamic therapy was originally designed for treatment of cancer cells but has been shown to be effective for acne. If the patient has deep scarring and pitting as a result of cystic acne, their appearance can be improved by dermabrasion. This dermatologic procedure involves mechanically scraping away the outer layers of skin and smoothing out its surface by applying motor-driven wire brushes or diamond wheels. Chemical dermabrasion is done by applying phenol or trichloroacetic acid to remove the scars. Nursing Management Teach the patient about the nature of their skin disease and give support while they are trying to cope with its physiologic and psychosocial effects. Acne can be particularly distressing to adolescents, who are often deeply concerned about their appearance and acceptance by their peers. Following through with the prescribed therapy is important. Studies have shown that adolescents in particular show less consistency in following the treatment plan when there is more than one medication or step to take (Dinulos, 2021). The face should be washed gently with a mild soap. Scrubbing the skin and using a harsh soap is damaging and contributes to inflammation. Special medicated soaps do not seem to be any better than a mild face soap. If the hair is oily, it should be shampooed frequently and kept off the face. Squeezing pimples and pustules is not recommended. This can press the sebum and accumulated material more firmly into the clogged duct, increase the chance of inflammation, and spread an infection to other parts of the skin and body. Blackheads and whiteheads are best removed by applying a prescription medication that causes peeling of the skin. The hands should be kept off of the face. Because the management of acne can go on for years and requires periodic evaluation by a dermatologist, patients and their families will need continued support and encouragement to follow the prescribed regimen. They will need to know the expected results of prescribed medications, any adverse reactions that might occur, and symptoms that should be reported immediately. Psoriasis Etiology, Pathophysiology, Signs, and Symptoms Psoriasis is a noncontagious, chronic, recurring skin disorder that typically appears as inflamed, edematous skin lesions covered with adherent silvery-white scales (Fig. 43.1). These scales are the result of an abnormally rapid rate of proliferation of skin cells. When the scales are removed, there is pinpoint bleeding. The plaques most often appear on the skin of the elbows, knees, and base of the spine. It also may affect the scalp, in which case it can be confused with seborrheic dermatitis. When the fingernails are involved, there can be pitting of the surface of the nails. The palms and soles also can be affected, making it difficult for the patient to carry out activities of daily living (ADLs). In some cases the skin eruptions of psoriasis are accompanied by inflammation of the joints, especially those of the fingers and toes. This is called psoriatic arthritis. Psoriasis affects about 2% of the U.S. population. There is a genetic predisposition for the disease. It is likely that an immunologic event triggers the disorder because the first lesion commonly appears after an upper respiratory infection. T cells are mistakenly activated and trigger immune responses that speed up the growth cycle of skin cells. There is increasing evidence that the chronic inflammation of psoriasis may be a multisystem disorder. In addition to psoriatic arthritis, chronic kidney disease, cardiovascular disease, malignancy, and psychiatric disorders have all been linked to psoriasis (Korman, 2020). Diagnosis and Treatment Diagnosis is by history, physical examination, and ruling out other skin disorders. Each case of psoriasis is treated individually. The disease is unpredictable, tends to go into remission spontaneously, and sometimes will clear up temporarily with or without treatment. Mild cases usually respond to steroid creams (triamcinolone acetonide [Kenalog]), but there is a possibility that eventually the disease will become resistant to steroids. Sunlight in moderate doses can help because the ultraviolet (UV) rays slow down the rate at which epithelial cells are produced. Extremes of UV radiation can have the opposite effect, resulting in an aggravation of the condition. Calcipotriene (Dovonex), a vitamin D analog cream, helps regulate skin cell production, decreasing the incidence of psoriasis plaques. Tar preparations also act to impede the proliferation of skin cells and have long been used to heal psoriasis lesions. They may be administered in the form of baths, topical applications, or shampoos. Combinations of artificial UV radiation and a coal tar product commonly are prescribed for severe cases. This usually requires hospitalization so that the dosage of each component of therapy can be measured precisely. A form of therapy called PUVA combines application of one of a class of drugs called psoralens, which penetrates the skin, with exposure to ultraviolet light type A (UVA). Antimetabolites have been used to treat severe psoriasis, helping to control the disorder by their antiproliferative action. Methotrexate is the most commonly used antimetabolite for this purpose. Acitretin (Soriatane) or cyclosporine is sometimes used. Brodalumab (Siliq) was FDA approved in 2017 as an injectable monoclonal antibody for use in psoriasis. It carries a black box warning regarding suicidal ideation and behavior. Other biologic agents shown to be efficacious include infliximab (Remicade), etanercept (Embrel), efalizumab (Raptiva), and alefacept (Amevive). Nursing Management Patients with psoriasis will need instruction about the nature of their disease, teaching about the purpose of the prescribed treatment, and information about ways to avoid aggravating it. The skin should be kept as moist and pliable as possible. Humidifiers to increase moisture in the environment are sometimes helpful. Lubricating lotions and creams should be approved by the dermatologist before they are applied. Minor scratches and abrasions and bacterial infections can trigger the formation of lesions at a new site. Because any irritation or break in the skin seems to stimulate the growth of psoriatic plaques in a person susceptible to psoriasis, the patient should be cautioned to prevent injury of any kind. This includes hangnails, damaged cuticles, blisters from poorly fitting shoes, scratches from pets, and potentially harmful agents in the environment such as radiation and chemicals. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (TEN) Stevens-Johnson syndrome (SJS) is an allergic reaction with skin manifestations resulting in necrosis and detachment of less than 10% of the epidermis. In 90% of patients, mucous membranes are affected. It can be caused by an infection, malignancy, or medication or be categorized as idiopathic. If greater than 30% of body surface area is affected, the disorder is called toxic epidermal necrolysis (TEN). Medications that have been shown to cause the condition include the anticonvulsants carbamazepine (Tegretol) and phenytoin (Dilantin), the antimalarial sulfadoxine-pyrimethamine (Fansidar), and the antibiotic sulfamethoxazole- trimethoprim (Bactrim, Septra). However, over-the-counter medications can also cause SJS/ TEN. Lesions that may be mistaken for chickenpox develop on the face, trunk, palms, extensor surfaces of joints, soles of the feet, and dorsum of the hands. The lesions have irregular borders and may have blistered, necrotic centers. There is evidence that a strong genetic predisposition may put patients at risk. Treatment of SJS/TEN involves discontinuing the drug and providing supportive care with fluids and nutrition. Wound care is similar to that for a burn. The lesions are painful, and analgesia is provided. Sedatives may be necessary. If not treated early, SJS/TEN can cause death. Bacterial Infections Etiology, Pathophysiology, Signs, and Symptoms Cellulitis is an infection of the dermis and subcutaneous tissue and is generally caused by Staphylococcus. It may occur as an extension of a skin wound, as an ulcer, or from furuncles or carbuncles. The area will be erythematous, swollen, and painful. It is treated with systemic antibiotics, and Burow soaks may be used to relieve pain. Burow solution is an astringent and topical antiseptic also called aluminum acetate solution. Furuncles (boils) or skin abscesses are inflammations of hair follicles. The organism responsible is usually Staphylococcus aureus. Any skin area with hair can be affected. Initially there is a deep, firm, red, painful nodule 1 to 5 cm in diameter. The nodule changes to a large and tender cystic nodule accompanied by cellulitis. The lesion may drain large amounts of pus and necrotic tissue. Carbuncles are a collection of boils that have multiple pus “heads,” most commonly occur on the back of the neck, the upper back, and the lateral thighs. It begins as a firm mass and evolves into an erythematous, painful, swollen mass. It may drain through many openings in the mass. Abscesses may develop with fever, chills, and malaise. Diagnosis, Treatment, and Nursing Management Diagnosis is by history and examination. Treatment of any infected mass with pus is drainage of the lesion. If necrotic tissue is present, debridement should be performed. Antibiotics are given when indicated. Nursing interventions are aimed at healing the infected areas and preventing recurrence. The patient is taught to avoid using cosmetic products and over-the-counter topical remedies on the affected areas. After incision and drainage, a dry absorbent dressing is applied and changed after 24 hours. Absorbent dressings are used until the wound stops draining, then a simple gauze covering is adequate. A clean washcloth and towel should be used for bathing each day until the wound is healed. Linens should be washed in hot soapy water and thoroughly dried before reuse. Viral Infections Herpes Simplex Herpes simplex virus type 2 (HSV-2) is most often associated with genital herpes, whereas herpes simplex virus type 1 (HSV-1) lesions are primarily orofacial (Fig. 43.2). Either type can cause lesions in the genital area as well as other regions of the body. Autoinoculation of the virus is possible by direct contact—for example, lips to fingers to genitals or lips to fingers to eyes. Health Promotion Preventing Spread of Herpesvirus Humans are the only species affected by HSV-1 and HSV-2, and the virus is spread by direct contact. The virus can be “shed” or transmitted even when symptoms are not present. Immunocompromised individuals are at greatest risk of acquiring the infection. If lesions are present, care should be taken to not have direct skin contact. Complementary and Alternative Therapies Lemon Balm for Cold Sores Lemon balm in a concentrated cream base has often been used to relieve the symptoms of herpes labialis (infection of the lips; commonly known as cold sores or fever blisters). In clinical studies it has been shown to shorten the healing period and prevent the spread of infection (Rakel, 2018). Etiology and Pathophysiology When initial infection occurs, the virus is imbedded in a nerve ganglion that innervates the site of the lesion. Reactivation of the virus causes new lesions to occur at the same site. The virus travels along the nerve to the site of the original infection. Reactivation is brought about by exposure to ultraviolet light, skin irritation, fever, fatigue, or stress. Signs and Symptoms An infection with HSV-1 appears as lesions on the lips and nares that are commonly called cold sores or fever blisters. The lesions are usually painful but do not cause systemic symptoms. Diagnosis, Treatment, and Nursing Management Diagnosis is by physical examination and history. Sometimes topical and oral acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex), available by prescription, hastens healing. The symptoms of itching and burning that accompany oral herpes infection sometimes can be minimized by applying warm compresses to the sores, followed by local application of tincture of benzoin or spirits of camphor to aid drying and facilitate healing. The disease usually is self-limiting, which means that it does not progress and will subside on its own, but it can recur. Contagion is possible up to 5 days after appearance of the lesion. Docosanol cream (Abreva) sold over the counter is a helpful treatment for this disorder. Patients should be cautioned to use good personal hygiene to prevent spreading the virus to the eyes and genital area and other body parts. Hand hygiene is a simple but essential part of preventing spread of the virus. Herpes Zoster Etiology and Pathophysiology Herpes varicella-zoster causes chickenpox (varicella), mostly in young children, and shingles (zoster) in all ages. In herpes zoster, the herpes viruses replicate in the peripheral nerve ganglia, where they lie dormant until reactivated by trauma, malignancy, stress, or local radiation (Fig. 43.3). Approximately 1 million cases per year occur in the United States, and about 1 in 3 people will be affected at some point in their lifetime (CDC, 2019). The risk is greater for immunocompromised individuals (those with cancer or human immunodeficiency virus/ acquired immunodeficiency syndrome [HIV/AIDS]). The varicella vaccine is given in two doses to children to prevent chickenpox. The first is given at age 12 to 18 months and the second at age 4 to 6 years. Older Adult Care Points Approximately 50% of individuals who live past 80 years of age develop shingles. The CDC recommends use of Shingrix, a vaccine that boosts the immune response to the zoster virus. Zostavax is a live virus vaccine that is about 50% effective in preventing shingles; it appears to be effective in attenuating the disorder if it occurs and is effective for about 6 years. Zostavax is contraindicated in immunocompromised patients (CDC, 2019). Signs and Symptoms Herpes zoster begins with vague symptoms of fatigue and low-grade fever and possibly loss of appetite. There may be only aching or discomfort along the nerve pathway with or without erythema. About 3 to 5 days after onset, small groups of vesicles appear on the skin. They usually are found on the trunk and spread halfway around the body, following the nerve pathways leading from the spinal nerve to the skin. Safety Alert Danger of Herpes Zoster Transmission No health care worker or visitor should be in contact with a patient who has chickenpox or shingles if they have never had the disease or the two doses of the varicella vaccination. A pregnant woman should not care for a patient with chickenpox or herpes zoster. The virus is highly contagious and can harm a fetus. The vesicles eventually change from small blisters to scaly lesions and are accompanied by pain and itching. The lesions usually affect only one side of the body or face. The pain of shingles often is quite severe. Pain can persist for several days or weeks after the skin lesions are completely healed. The pain of postherpetic syndrome is not easy to control. Diagnosis and Treatment Diagnosis is by history and physical examination. There is no cure for herpes zoster. The condition can persist for months, especially in older and debilitated patients. Herpes infections may be recurrent because complete immunity does not occur. The earlier the condition is diagnosed and treatment begins, the better are the chances to decrease the amount and duration of the associated pain (CDC, 2021). Symptomatic treatment typically involves administering an analgesic to relieve pain. Capsaicin, an over-the-counter analgesic that is applied topically five times a day, decreases pain for some patients. A paste made from aspirin and water placed on the lesions decreases pain for others. Antibiotics may be prescribed prophylactically against secondary bacterial infection of the lesions. Most health care providers prescribe oral acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) to diminish the extent or duration of the lesions. Valacyclovir is used only in otherwise healthy patients. Famciclovir, if given within the first 2 to 3 days of the outbreak, seems to shorten the duration of the chronic pain that typically follows shingles. Tricyclic antidepressants and gabapentin (Neurontin), an anticonvulsant drug, have been used with variable success at controlling pain. Narcotic analgesics are avoided if possible because they can lead to addiction when used for an extended time. If the pain persists and is intractable, the provider prescribes a corticosteroid to reduce inflammation. Vidarabine, administered intravenously (IV), is sometimes given to patients who have an immune deficiency. It is usually effective in reducing, if not completely relieving, the pain. Although shingles may be difficult to live with while the disease is running its course, the only lasting complication from the disease is postherpetic neuralgia. More serious but rare complications include outbreaks near the eye, in which case it can cause blindness or disseminated disease that can be life-threatening. The prognosis is less favorable in patients who have an underlying malignancy or who are immunocompromised. Nursing Management Care includes symptomatic relief from the pain and itching and prevention of a secondary bacterial infection. Cold compresses (with Burow solution), calamine lotion, and diversional activities are sometimes helpful. Rest and adequate nutrition can promote healing and shorten the acute phase of shingles. Teaching imagery, deep muscle relaxation, or use of distraction activities may help decrease pain. Evidence supports initiation of isolation procedures based on symptoms rather than waiting for a confirmed diagnosis. If lesions are disseminated, meaning widely dispersed, or if the patient is immunocompromised, airborne and contact precautions are necessary until all the blisters are crusted. If the lesions are localized and can be kept covered and the patient is not immunocompromised, Standard Precautions are sufficient (CDC, 2019). Fungal Infections Fungal infections are called mycoses; systemic fungal infections involving the lungs and other internal organs are called systemic mycoses. There are two groups of fungi that cause infections in humans: (1) fungi that are truly pathogenic to humans and (2) fungi that cause opportunistic infections (can cause an infection when the host has an altered immune system). True pathogenic fungi can cause infection in an otherwise healthy person, but relatively few fungi are able to do this. Fungal infections are rarely fatal if they involve only the superficial tissues of the body. Nevertheless, mycotic skin infections can be exasperating because they are difficult to diagnose and often resistant to treatment. The most common types of fungal infections involving the skin are tinea pedis (athlete’s foot or dermatophytosis), tinea cruris (jock itch), tinea capitis (commonly known as ringworm), and tinea barbae (barber’s itch). Moniliasis (thrush) is a fungal infection that can attack the mucous membranes of the mouth, rectum, and vagina (candidiasis). (This condition is discussed more fully in Chapter 11.) The skin fungal infections produce itching, some swelling, and a breakdown of tissue. Because fungi thrive in warm, moist places, a tropical climate or other environmental factors that produce prolonged heat and moisture can encourage the development of fungal infections. Older adults are prone to develop fungal infections of the fingernails or toenails (onychomycosis) (Fig. 43.4). Hands and feet should be thoroughly dried after becoming wet, with special attention to drying between the toes after the bath or shower. Nails should be cut straight across without rounding the edges. Wearing clean socks daily helps prevent fungal growth. In the toenails, the condition may become quite painful. Treatment requires oral antifungal medication daily for several months or topical agents daily for a year or more. Complementary and Alternative Therapies Treatment of Nail Fungus Tea tree oil used topically daily on the nail and cuticle has been successful in treatment of yeast and fungal infection (Micozzil, 2019). It must be used regularly to be effective and may take weeks or months to cure the infection. Another inexpensive treatment that may work with consistent daily use is the topical application of Vicks VapoRub twice a day. This salve contains camphor, menthol, and eucalyptus. It seems to arrest the development of further fungal growth, allowing a fungus-free nail to grow. It takes about 6 months of treatment and is not effective for everyone. There are many side effects of the oral antifungal medications. Liver function should be monitored during drug administration. Diagnosis of fungal infections is confirmed by microscopic examination of skin scrapings that have been treated with potassium hydroxide (KOH) solution. Fungal specimens generally show the typical filaments of fungal organisms. Patients should be taught how to prevent recurrence of fungal infections. Tinea Pedis Tinea pedis (athlete’s foot) affects the feet, particularly between the toes. The infection may spread to the entire foot and cause blistering, peeling, cracking, and itching. If it continues unchecked, it can spread to other parts of the body. The condition can be complicated by a severe bacterial infection. Etiology, Pathophysiology, Signs, and Symptoms Most cases of tinea pedis are contracted and spread in swimming pools, spas, showers, and other public facilities of this type. Trichophyton mentagrophytes and T. rubrum are the usual infecting agents. These organisms may be normal flora that spread easily under conditions of excessive warmth and moisture. The skin between the toes becomes inflamed and develops cracks that become painful fissures. Intense itching is common. Diagnosis and Treatment Diagnosis is by physical examination. Treatment of tinea pedis consists of keeping the area dry, clean, and exposed to the air and sunlight as much as possible. Clean cotton socks should be worn every day, and the affected areas between the toes should be separated by gauze or cotton. Soaks of Burow solution help. Various topical antifungals, including ciclopirox (Loprox), miconazole, clotrimazole (Mycelex), econazole (Spectazole), ketoconazole (Nizoral), and naftifine (Naftin), can be prescribed. Most of the prescription medications are available over the counter in a lesser concentration. Some medicated powders, such as undecylenic acid–zinc undecylenate, work to keep the feet dry and also help control fungal growth. Systemic treatment for stubborn infection includes oral itraconazole (Sporanox) and terbinafine (Lamisil). Nursing Management Encourage the patient to keep the feet clean and dry and to wear clean cotton socks every day. Daily application of the topical agent must be done diligently to eradicate the problem. The patient should only use their own towel, and the shower or tub should be thoroughly cleaned and disinfected after bathing to prevent transmission to other family members. Personal footwear should be used in public places, such as the swimming pool and in the showers at fitness centers, and feet should be washed and dried thoroughly after using public facilities. Parasitic Infections Pediculosis and Scabies Etiology and Pathophysiology The parasites that cause pediculosis and scabies are found throughout the world in all types of climates. They can infest anyone. The parasites are particularly troublesome, however, where people live in crowded conditions and do not maintain their personal hygiene. The occurrence of pediculosis and scabies in the United States has recently increased significantly because of the growth of the homeless population and communal living. These parasites are often found among schoolchildren. The parasites are also found in nursing homes, dormitories, and sometimes hospitals. Three basic types of lice that infest human beings are (1) the head louse, Pediculus humanis capitis; (2) the body louse, P. humanis corporis (Fig. 43.5); and (3) the pubic or crab louse, Phthirus pubis. In addition, human beings also may be infested by Sarcoptes scabiei, the mange mite that produces scabies. The lice are oval and 2 to 4 mm long. All types are acquired by contact with infested people or their clothing, bed linens, and bedding. Pets have also been known to carry lice and the scabies mite. Signs and Symptoms The most prevalent symptom of louse infestation is severe itching. The resultant scratching can lead to excoriation of the skin and secondary infection causing impetigo, furunculosis, and cellulitis. Systemic infections are not commonly associated with louse infestation, but they carry bacteria that can cause epidemics such as louse-borne typhus, trench fever, and louse- borne relapsing fever (Guenther, 2019). If the lice infest the eyelids and eyelashes, the eyelids become red and swollen. Swelling may also occur in the lymph glands of the neck of a person heavily infested with head lice. The scabies mites burrow under the top layers of the skin and live their entire lives there. They are more likely to be found in the skin between the fingers and toes, in the groin, and in other areas where there may be folds of skin. Excretions from the mites produce irritation with intense itching and blistering. Secondary infection is not uncommon with scabies, and some deaths have occurred when the scabies infestation has led to pneumonia or septicemia. Diagnosis Diagnosis is by body inspection and by examination of skin scraping of a lesion under the microscope. Lice eggs (known as nits) are deposited at the base of hair shafts and can be seen on close inspection. Scabies causes curved or linear white or erythematous ridges in the skin that are easily visible. Treatment The drugs most commonly used and considered most effective against lice and scabies are permethrin (Nix, Elimite), pyrethrins (RID), and malathion (Ovide). Some are available over the counter. These substances must be used carefully and the patient’s liver function monitored because they can be very toxic. They are available as creams, lotions, and shampoos. A fine- toothed (nit) comb is then used to remove the nits (eggs) that may have remained on the hair. Benzyl alcohol lotion 5% (Ulesfia) is effective for head lice. It works by suffocating the lice. The amount required is based on the length of the hair, and a second treatment is required in 7 days (Guenther, 2019). Nursing Management Contact precautions are recommended. In addition, clothing, bedding, hats, stuffed animals, and other infested articles must be decontaminated to prevent reinfection. Laundering in hot water and machine drying using the hottest cycle is effective. Dry cleaning of nonwashable bed coverings or clothing can be effective. Mattresses, upholstered furniture, carpets, and other articles should be sprayed with a specific disinfectant. All combs and brushes should be soaked in very hot water for more than 5 minutes. For items that cannot be cleaned, such as some stuffed animals, sealing them in plastic bags with the air expelled for 14 days can be effective. All family members must receive instruction about the infection and ways to prevent reinfestation. Noninfectious Disorders of Skin Skin Cancer Skin cancer is often neglected because no pain is associated with it and patients fear that treatment will involve extensive or disfiguring surgery. More than 5 million cases of basal cell and squamous cell cancers occur in the United States each year. These are highly curable cancers. It is expected that 100,350 persons will have been diagnosed with melanoma, the most serious type of skin cancer, in 2020 and that 6850 deaths from melanoma will occur in that year (American Cancer Society, 2020). Most melanoma deaths could have been averted through early diagnosis and treatment. Kaposi sarcoma and T-cell lymphoma are discussed in Chapter 11. Etiology and Pathophysiology Several factors predispose an individual to developing skin cancer. Among these are internal changes in the cells that may be caused by hereditary factors and external influences such as chronic exposure to ionizing radiation, petrochemicals, or vinyl chloride or to other irritants in the environment. Sunburn as a child is a particular risk factor. Because characteristics are inherited, susceptibility to skin cancer tends to run in families. Blue-eyed blonds and redheads seem to be most susceptible, probably because they lack sufficient pigment to protect the skin cells from outside irritants. Those with a light complexion have a 24-fold greater risk of developing melanoma than African Americans, and before age 45 years the risk is higher for women than men (American Cancer Society, 2020). Heavy exposure to UV radiation is a risk factor; this can be from alteration in the ozone layer inflicting much quicker damage to skin with much less sun exposure than in years past or long periods in the sun. Indoor tanning beds have been labeled “carcinogenic to humans” by the International Agency for Research on Cancer. The quickly proliferating skin cells of the younger generation are even more susceptible to this type of damage, and it is mostly the young who spend large amounts of time in the sun. You should instruct all people about the dangers of sunning without an appropriate protective sunscreen. Think Critically You and a friend are going on a beach vacation. How will you prepare? What advice will you give your friend for time spent on the beach? Signs, Symptoms, Diagnosis, and Treatment Signs and symptoms vary according to the type of lesion. Diagnosis is by examination, biopsy, and pathology study. The three main types of skin malignancy are basal cell carcinoma, squamous cell carcinoma, and melanoma. Basal cell carcinoma usually appears first as a small, scaly area and tends to become larger as the disease progresses (Fig. 43.6). It occurs most commonly on the face and trunk. As the scales shed, there is a small amount of bleeding, and a scab will form. When the scab is shed, the affected area becomes wider, and it is bordered by a waxy, translucent, raised area. If such a sore has not healed within a month, it may be a basal cell carcinoma. This spreading may continue very gradually during several months or years. Even though these malignancies do not metastasize, they can invade underlying tissues, and death can result from complications such as infection or hemorrhage from encroaching into a blood vessel. Small lesions can be removed under local anesthesia in a health care provider’s office. Larger lesions respond well to radiation therapy. Squamous cell carcinoma is caused by sunlight, affects the epidermis, and can become invasive and metastasize to other areas of the body. It appears on the head and neck most frequently. The tumor begins as a small nodule that rapidly becomes ulcerated (see Fig. 43.6). Treatment must begin early if the condition is to be relieved before the skin cells sustain extensive damage. Surgical procedures involve total removal or destruction of the lesions and the surrounding tissues that have been invaded. Cryotherapy, topical chemotherapy, laser surgery, and either topical or injected immune response modifiers are all used as therapies. Older Adult Care Points Actinic keratoses are very common among older adults. They appear on fair-skinned people as a small, scaly, red or grayish papule, particularly on areas of skin that are often exposed to the sun. These lesions should be removed because they can evolve into a squamous cell carcinoma that can grow rapidly and metastasize. Malignant melanoma is the least common form of skin cancer but causes most skin cancer deaths. It arises from pigment-producing cells and varies in its course and prognosis according to its type (see Fig. 43.6). Causative factors are genetic predisposition, solar radiation, and steroid hormone influence. There are several types of melanoma, but the three major kinds of malignant melanoma are superficial spreading, nodular, and lentigo maligna melanoma. In general, the superficial lesions can be cured, but the deeper lesions tend to metastasize more readily through the lymphatic and circulatory systems. Characteristics of the three main types of skin cancer are shown in Table 43.1. Malignant melanoma always requires surgical removal of the tumor and excision of adjacent tissues and possibly nearby lymphatic structures. Chemotherapy may be used to destroy tumor cells believed to have migrated beyond the tumor site. Radiation therapy usually is not indicated unless there is extensive metastasis. The radiation does not eliminate the disease, but it can relieve symptoms by reducing tumor size. Interferon alfa-2b has been found to prolong life in patients who have undergone malignant melanoma surgery and are at high risk for systemic recurrence (American Cancer Society, 2020). In advanced cases, newer immunotherapy drugs are being used to enhance immune function. Ipilimumab (Yervoy), a CTLA-4 inhibitor, has been shown to prolong life. An oral agent, vemurafenib (Zelboraf), a BRAF inhibitor, is being used for late-stage melanoma and is the first drug approved that uses fragment-based drug discovery. In this method, small chemical fragments are grown or combined to produce a drug with a higher affinity for binding with the biological target. In patients with malignant melanoma and a known BRAF mutation, treatment with vemurafenib has a response rate of 50%. However, over several months the medication is less effective. Giving it with other medications that alter immune function is showing promising results (Dummer et al., 2018). The type of removal of cancerous skin tissue will depend on the type of malignant growth present. In all but the most extensive growths, treatment is relatively simple and completely successful if started early. Although benign precancerous lesions do not inevitably develop into malignant lesions, the most advisable course of action is to remove them when they are first diagnosed. Removal is performed by surgery, electrodesiccation (tissue destruction by heat), cryosurgery (tissue destruction by freezing with liquid nitrogen), topical application of 5- fluorouracil (5-FU), interferon therapy, laser therapy, and molecular therapy. Radiation therapy is sometimes used to destroy the cancer. Nursing Management While performing daily care of patients, you often are in a position to notice these lesions in their early stages and should do your best to persuade the person with such a lesion to seek prompt medical attention. For hospitalized patients, notification of the health care provider is indicated. It is also helpful to teach assistive personnel the cues and clues that help recognize these developments. Three Major Types of Skin Cancer Type Characteristics Basal cell carcinoma Slowly enlarging, firm, scaly papule. Crusted or ulcerated center that may be depressed; has pearly (semitranslucent) raised border.Dilated capillaries around lesion. Accounts for 70% of all skin cancers. Rarely spreads and is easily treated. Squamous cell carcinoma Appearance variable. Commonly seen as well-defined, irregularly shaped nodule or plaque. May be elevated, nodular mass, or fungated mass. Varying amounts of scale and crusting. May have ulcerated center. Predominantly on sun-exposed areas: head, neck, hands; 75% occur on the head. Spreads rapidly. Malignant Melanomas Superficial spreading melanoma (SSM) Appears in a variety of colors: white, red, gray, black, or blue over a brown or black background. Has irregular surface and notched border. Small tumor nodules may ulcerate and bleed. Horizontal growth can continue for years. Vertical growth worsens prognosis. Nodular malignant melanoma (NMM) Nodule with uniformly grayish black color; resembles a blackberry. May be flesh colored with specks of pigment around base of nodule. Itching, oozing, and bleeding may occur. Prognosis less favorable than superficial type. Lentigo maligna melanoma (LMM) Relatively rare. Arises from a lesion that resembles a large, flat freckle that is of variable color from tan to black. Has irregularly spaced black nodules on the surface. Typically located on the back of the hand, face, and neck. Develops very slowly; may ulcerate. Acral lentiginous melanoma Rarest type of melanoma. Located on the palms of the hands, on the soles of the feet, or under fingernails and toenails. Not related to sun exposure. Appears as a dark streak under the nail. On other areas presents as an odd-shaped black, gray, tan, or brown mark with irregular borders. Because people who have skin cancer run a high risk of eventually developing another malignancy, either at the original site or elsewhere in the body, they should visit a provider at least once a year after the skin cancer has been cured. Although most skin cancers are easily curable, they should not be considered harmless and something to forget about after treatment (see Chapter 8). Another nursing function is educating the patient about the type of cancer and helping to decrease fear. For many people, the diagnosis of “cancer”—even of an easily cured skin lesion— causes a change in body image and possibly in self-esteem. You can assist patients to talk about concerns and the future, point to community resources and support groups, and answer questions about treatment. Pressure Injury (ULCERS) When a patient is on bed rest or constantly sitting because of paralysis, pressure against the skin in various areas interferes with circulation. Because cells die very quickly without adequate blood supply, pressure injury can develop. Depending on the patient’s general condition, weight, and other factors, skin damage may occur within a few hours to a few days. Areas most prone to pressure injury are those over bony prominences. When the patient is placed in a position in which the bone is pressing on the skin where the skin is against the bed, the circulation to that area is compromised (Fig. 43.7). Shearing action (in which superficial layers of tissue are pulled and stretched across deeper layers of tissue) can cause damage to the skin if the patient is slid along the sheets for positioning, rather than lifted. The National Pressure Ulcer Advisory Panel (NPUAP) defines pressure injury as injury to the skin caused by pressure alone or in combination with shear. The term ulcer has been replaced by injury, and the term ulcer is used only if an ulceration is present (NPUAP, 2019). Risk Factors and Prevention Every patient needs and deserves good skin assessment, but there are risk factors that make some patients more susceptible to problems, such as confinement, immobility, incontinence, malnutrition, decreased level of consciousness or confusion, obesity, diabetes mellitus, dehydration, edema, excessive sweating, and extreme age. Preventing tissue injury from pressure is far more desirable, more cost-effective, and less time-consuming than treating them. In fact, the importance of excellent nursing care is now a financial issue because Medicare and Medicaid levy penalties for hospital-acquired pressure injuries (Rondinelli et al., 2018). Pressure relief, positioning, padding, use of pressure-relief devices, adequate nutrition, and excellent skin care are the hallmarks of pressure injury prevention. Box 43.2 presents interventions for preventing tissue injury from pressure based on the Institute for Clinical Systems Improvement’s health care protocol. Pressure injury can be very costly to the health care system, costing about $10 billion and 60,000 deaths annually (The Joint Commission, 2021). Nutrition Consideration Nutrition and Wound Healing Ongoing research is being conducted about the optimal amounts; however, increased energy (calories); protein; zinc; and vitamins A, C, and E have been shown to reduce pressure injury and promote healing of existing tissue injury (Saghalenini, 2018). Signs and Symptoms Once a patient has developed a pressure injury, treatment depends on the stage of the lesion. Several kinds of preprinted forms can be used to assess the risk of developing pressure ulcers. These assessment tools consider the general condition of the skin, control of urination and defecation, mobility, mental status, cleanliness, and nutritional status. They provide a more systematic approach to evaluate a patient’s potential for pressure ulcer development. Many agencies use either the Braden scale system (Fig. 43.8) or the Norton system for systematic assessment of the skin. The presence and stage of any tissue injury must be documented on admission to any health care facility or service. Classifying an ulceration or injury can also be helpful in evaluating the effectiveness of treatment and progress toward healing and repair. The NPUAP has updated pressure injury definitions for the prediction and prevention of pressure injury and a staging system for classification: Suspected deep tissue injury: Intact skin with a purple or maroon discoloration. Tissue may be firm, boggy, painful, cool, or warm. Stage 1: An area of intact skin that is reddened, deep pink, or mottled that does not blanch (Fig. 43.9). Stage 2: Partial-thickness skin loss involving the dermis and/or epidermis. The skin appears blistered or abraded or has a shallow crater. The area surrounding the damaged skin is reddened and probably will feel hot or warmer than normal (Fig. 43.10). Stage 3: The skin is ulcerated. There is a crater-like ulcer, and the underlying subcutaneous tissue is involved in the destructive process. The ulcer may or may not be infected. Bacterial infection is almost always present at this stage, however, and accounts for continued erosion of the ulcer and the production of drainage (Fig. 43.11). Best Practice for the Prevention of Pressure Injury Assess the skin of all patients every 8 to 24 hours (interval depends on condition), paying particular attention to the bony prominences (see Fig. 43.7) Reposition patients on bed rest at least every 2 hours; use a written schedule for systematically turning and repositioning each patient. Use positioning devices, such as pillows, foam wedges, and padding, for patients on bed rest to keep body prominences from being in direct contact with one another. For patients on bed rest who are completely immobile, use devices that totally relieve pressure on the heels by raising the heels off the bed. Do not use donut-type devices. When the side-lying position in bed is used, avoid positioning directly on the trochanter. For patients on bed rest, maintain the head of the bed at the lowest degree permitted by the medical condition. Limit the time the head of the bed is elevated. Use lifting devices, such as a trapeze or bed linens, to move patients rather than dragging those who cannot assist during transfers and position changes. For patients with limited mobility, use a pressure-reducing device on the bed, such as a foam, static air, alternating air, gel, or water mattress. Minimize skin injury caused by friction and shear forces by proper positioning and correct transferring and turning techniques. Reduce friction injuries by using lubricants, protective films, protective dressings, and protective padding. Skin cleansing should occur at the time of soiling and at routine intervals based on patient need and preference. Do not use hot water and use a mild cleansing agent that minimizes irritation and dryness of the skin. Cleanse gently, minimizing the force and friction applied to the skin. Keep the environmental humidity above 40% and prevent exposure to cold. Treat dry skin with moisturizers. Do not massage bony prominences. Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage. When sources of moisture cannot be controlled, underpads or briefs that absorb moisture and present a quick-drying surface to the skin should be used. Use an incontinence management program for incontinent patients. Check for incontinence at least every 2 hours. Correct inadequate dietary intake of protein and calories with nutritional intervention either by oral supplementation or enteral or parenteral feedings. For wheelchair-bound patients, use a pressure-reducing device such as those made of foam, gel, air, or a combination of items. Do not use donut-type devices. Positioning of wheelchair-bound patients should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief by device or repositioning. Any person at risk for developing a pressure ulcer when sitting in a chair or wheelchair should be repositioned, shifting the points under pressure at least every hour (every 15 minutes is preferable); patients who are able should be taught to shift weight every 15 minutes. If a potential for improvement of mobility and activity status exists, institute a rehabilitation program. Maintain current activity and mobility status with a range-of- motion exercise program. Stage 4: There is deep ulceration and necrosis involving deeper underlying muscle and possibly bone tissue. The ulcer can be dry, black, and covered with a tough accumulation of necrotic tissue, or it can be made up of wet and oozing dead cells and purulent exudates. Depth can be determined (Fig. 43.12). Unstageable: Full-thickness wounds with eschar and/ or tissue that obscures depth determination. Assignment Considerations “On-Time” The On-Time Quality Improvement for Long-Term Care was developed by the Agency for Healthcare Research and Quality (AHRQ). Part of the program includes assessment tools that can be completed by certified nursing assistants. The tools provide information about nutritional status, behavior, incontinence, and contributing factors. Data are then made available to health care providers, nurses, dietitians, and other care providers. The program fosters teamwork and communication and helps identify patients who are at risk for pressure ulcers (AHRQ, 2017). A technology called pressure mapping helps identify areas of high pressure. The patient lies (or sits) on a sensor-filled mat, and the mat sends data to a computer, which creates a display of color-coded images. Red areas indicate higher pressures, and blue or green areas suggest lesser pressures. The patient can then be repositioned accordingly. The technology is an adjunct to, not a replacement for, good nursing assessment (Padula et al., 2020). It is being used to identify best practice to prevent tissue injury from pressure and shearing. Treatment and Nursing Interventions Debridement Removal of any eschar (dead, necrotic tissue) must occur for a pressure ulcer to heal. The exception is a heel ulcer with dry eschar that has no edema, erythema, drainage, or boggy tissue. Debridement can be done surgically with forceps and scissors or mechanically. Mechanical debridement is accomplished by whirlpool baths, wet-to-dry saline dressings, dextranomer beads sprinkled over the wound, or other proteolytic enzymes or chemical products that break down the dead tissue and absorb the exudate. Wet-to-dry dressings are not recommended because of thedamage that occurs to new granulation tissue when removed. Dressings that keep the wound moist should be used. Carefully read the instructions for whatever product is being used. Surgical debridement may be done in the patient’s room, the health care provider’s office, or the surgical suite depending on the depth and extent of the wound. Surgical debridement may require a skin graft to cover the area exposed. Whenever surgical debridement, forceful irrigation, or whirlpool debridement is to occur, provide sufficient analgesia for the patient because the procedure is painful. Cleansing and dressing Many hospitals and larger long-term care facilities have a wound care nurse specialist who oversees wound treatment; you should consult these specialists for valuable advice about wound cleansing and dressing materials. After sharp debridement with bleeding, clean and dry dressings are used for 8 to 24 hours, then moisture-retaining dressings are applied. Ulcers are cleaned whenever the dressing is changed. Normal saline or other nontoxic solutions, such as Shur-Clens, and light mechanical action with sponges or irrigation equipment is a way of cleansing that prevents disruption of granulation tissue. At least 250 mL of solution and a 30- mL syringe with a small catheter or 18-gauge blunt needle attached is used to irrigate and to reach undermined areas and tunnels. A reddened wound bed requires gentle irrigation with a 30- to 50-mL needleless syringe to prevent damage to newly developing tissue. Wound dressings are selected according to the characteristics of the wound. Common dressing materials include moisture retentive dressings, hydrogel dressings, hydrocolloid wafers, alginates, biologic dressings, and absorptive dressings. Use hypoallergenic tape when tape is necessary. Choose a dressing that keeps the ulcer moist and the surrounding skin dry. Prevent abscess formation by loosely filling all cavities with dressing material. Pressure must be kept off the wound for it to heal. Other treatment methods Application of electrical stimulation increases the rate of healing of pressure ulcers, venous leg ulcers, and diabetic foot ulcers. Application of an electrical current to the skin has been in clinical use for several decades. The therapy requires bulky equipment for generation and delivery of the electrical therapy. Researchers are currently developing a bandage that is wired to deliver the therapy. The electrical charge is generated by the movement of the chest wall during breathing from a band placed around the chest that contains nanogenerators (University of Wisconsin-Madison, 2018). Negative-pressure wound therapy (NPWT) is used effectively for chronic wounds, speeding healing time. NPWT can also be used on other types of wounds. A foam sponge is cut to fit into the open wound and an occlusive adhesive sheet is placed over the wound, extending past the wound edges. A hole is made in the adhesive, and a suction port is placed. Suction tubing is attached to the port and then to the vacuum source. The foam dressing facilitates suction applied to the full surface of the wound. The subatmospheric pressure stimulates the formation of granulation tissue and pulls away exudate from the wound (Gestring, 2020). For an ulcer that will not heal using other methods, hyperbaric oxygen therapy may be prescribed if the equipment is available in the community. The patient is placed in the hyperbaric oxygen chamber for the treatments. Tissue becomes flooded with more oxygen than is normally available when breathing atmospheric-pressure air. This is an effective treatment for other difficult-to-heal wounds as well (Jones & Cooper, 2020). Documentation Pressure ulcers should be measured and documented when they are discovered and at least once a week thereafter. Document the characteristics of the wound and any exudate present. Exudate is usually purulent (containing pus) or serosanguineous (containing serum and blood). Serosanguineous exudate is amber colored and blood tinged. Purulent drainage may be one of several colors (Table 43.2). All aspects of risk assessment, preventive measures instituted, objective description and measurement of pressure ulcers, treatment, and progress toward healing are documented regularly in the patient’s chart. The Pressure Ulcer Scale for Healing (PUSH) tool is a good way to objectively document your findings. Photographs are usually taken of the ulcer on discovery and during treatment to document progress. Burns Etiology and Pathophysiology Burns are injuries to the skin caused by exposure to extreme heat, hot liquids, electrical agents, strong chemicals, or radiation. Inhaling smoke or fumes also causes injury. About 450,000 Americans seek care for burns each year. Most burns are relatively minor, but approximately 34,000 patients are hospitalized for burns each year. Fire and burns kill approximately 4000 people each year in the United States (American Burn Association, 2020). Thirty years ago most patients with burns to more than 50% of the body did not survive. Today, because of fluid resuscitation, burn wound excision and grafting techniques, new skin coverings, and nutritional supplementation, a patient may survive a 99% burn. Today, 96.7% of patients treated in a burn center survive. Many live with lifelong disabilities and scarring. Color of Purulent Exudate and Probable Pathogen Color Exudate = May Indicate Beige with a fishy odor = Proteus Brown with a fecal odor = Bacteroides Creamy yellow = Staphylococcus Green-blue with a fruity odor = Pseudomonas Electrical burns damage tissue deep within the body. The extent of damage is not always visible, and the entrance site and exit site may appear small. Cardiac monitoring should be initiated even if the patient does not complain of chest pain. Chemical burns result from accidents in homes or industry. The severity of the injury depends on the duration of contact and the concentration of the chemical. The amount of tissue exposed to the chemical and the action of the chemical affect severity. Alkalis (e.g., industrial cleaners and fertilizers) cause greater injury and burn by liquefying tissue. Acids damage the tissue by coagulating cells and proteins. Chemicals for swimming pools, rust removers, and bathroom cleaners are acids. Organic compounds damage tissue by their fat solvent action. Radiation skin injury is typically from therapeutic radiation treatment. In industries in which radioactive isotopes are used, the degree of injury depends on the amount and type of energy deposited over time. See Chapter 8 for care of skin damaged by radiation treatments. Burns cause an acute inflammatory response (see Chapter 6). Serious burns have local and systemic effects. All burns should be considered potentially life threatening until they are thoroughly assessed. When a burn area is large, the inflammatory response can result in a massive shift of water, electrolytes, and protein into the tissues. This causes severe edema. Evaporation from denuded areas is four times that from intact skin. Hyperkalemia occurs when potassium is released from the damaged cells. Hyponatremia is caused by the stress response and potassium shifts. Metabolic acidosis develops. The loss of fluids from the vascular space leads to hypovolemia with low blood pressure and possible hypovolemic shock. Hematocrit will be increased because of concentration of the blood, which is missing the components that have shifted into the tissues. The increased viscosity of the blood causes slowing of blood flow in the small vessels, which in turn causes tissue hypoxia. There is danger of kidney failure from both the hypovolemia and the cellular debris that the kidneys must clear from the body. If the burn was caused by a fire, lung tissue injury from inhalation of heat and smoke may cause alveolar edema. The decreased perfusion to other organs causes changes in the gastric mucosa that impair its integrity. A type of ulcer called a Curling ulcer can occur within 24 hours. The stress response to the trauma releases catecholamines, aldosterone, cortisol, and antidiuretic hormone. A hypermetabolic state results, and unless nutrition needs can be met, the body falls into negative nitrogen balance. A low-grade fever may develop as core temperature rises. Fluid replacement is essential. Signs, Symptoms, and Diagnosis Burn severity depends on the cause, the temperature and duration of contact, the extent of the burned area, and the anatomic site of the burn. Signs and symptoms vary from slight reddening of the skin to full loss of tissue down to bone with black, charred areas. Blisters may form. A dry, scablike crust forms over a superficial burn. Eschar is a hard, leathery layer of dead tissue that results when there has been a full-thickness injury. It is dark brown to black. Diagnosis of the depth of the burn is made based on a classification system. Classification of Burns The classification of burns is based on the amount of the body surface that has been burned and the depth of the burn. The extent of a burn is roughly calculated outside of the hospital according to the “rule of nines” and is expressed as a percentage of total body surface (Fig. 43.13). The figures used in this method are fairly accurate for gross assessment in adults. The Lund-Browder classification or the Berkow chart can be used to compute the depth of the burn and the extent of the injury according to relative age, and the total burn estimate is used as the basis for treatment. Burns are a prevalent pediatric injury as well, and children cannot be assessed using the standard rule of nines. Similar charts with different percentages or charts specific to pediatric patients such as the pediatric Lund-Browder chart should be used. The depth of a burn is more difficult to determine because various gradations of injury are sustained in a major burn. Some small patches may be more deeply burned than the areas adjacent to them. Burn depth originally was classified according to degrees, a first-degree burn being the most superficial and a fourth-degree burn being the deepest. A more current method to evaluate the depth of burns is based on the layers of skin that have been damaged (Fig. 43.14). Epidermal or first-degree burns involve only the superficial epidermal layer and usually do not need treatment. Superficial partial-thickness wounds (second degree) (Fig. 43.15) are those in which the epidermal appendages (sweat and oil glands and hair follicles) are not destroyed and the wound will heal by itself if no further injury occurs from either infection or inappropriate treatment (see Chapter 5, Table 5.1 for the phases of wound healing). Deep partial-thickness wounds (second degree) include tissue through the lower layer of dermis and will require surgical treatment. Full-thickness wounds (third degree) (see Fig. 43.15) involve all layers of skin and the destruction of the epidermal appendages. Wounds of this type will require grafting for the wound to heal and for optimal function to be restored. Fourth-degree wounds involve underlying structures such as fat, muscle, or bone. Table 43.3 provides a guide for estimating the depth of a burn. Emergency Treatment First, all burn patients are treated as trauma patients. Establishment and maintenance of an airway is the first priority. The patient may have other life-threatening injuries besides their burns. Hemorrhage does not usually occur with burns. If a burned patient shows signs of bleeding, they must be checked for some other type of injury, such as a penetrating wound, fracture, or laceration that occurred at the same time they were burned. Generally, patients are undressed and covered with a sterile or freshly laundered sheet; however, clothing that is stuck to the burn area is not removed before the patient is in the hospital. Rings, bracelets, and watches should be removed from injured extremities to prevent a tourniquet effect when swelling occurs. Salves, ointments, or any greasy substance should not be applied to a burned area because the removal of greasy substances is very painful and increases the possibility of infection. Blisters should not be disturbed initially because they serve as a protective covering over the wound. Box 43.3 outlines first aid for minor burns. Patients with serious burns are generally given nothing by mouth. Oxygen is administered if pulse oximetry indicates a problem with respiratory function or if inhalation injury is suspected. Assessment for carbon monoxide inhalation includes checking the mucous membranes for a cherry-red color. Intravenous fluid therapy and more extensive medical treatment are started as soon as possible. The American Burn Association has identified criteria for minor and major burn injuries. It recommends that all major burn injury patients be treated in a burn center. Every emergency department has guidelines that indicate criteria for transferring a victim to a burn center. Emergent Phase of Burns The emergent phase averages 24 to 48 hours but may last for as long as 3 days. It begins with fluid loss and edema formation and lasts until edema fluid is mobilized and diuresis begins. The first hour of treatment after burning can be crucial to the eventual outcome of a serious burn. Other life-threatening injuries must be treated first. If possible, details of the nature of the accident should be obtained so that a more thorough assessment can be made. Knowing the causes of the burn and whether there is any possibility of thermal damage to the respiratory tract can alert the team to the specific needs of the patient. The depth and extent of the burn area are estimated, and multiple IV lines are established. A tetanus toxoid injection is given in the emergency department; it is the only intramuscular injection given initially. Respiratory support There is a potential for respiratory obstruction if upper airway passages have been burned. Swelling will occur, and it will become increasingly difficult for the patient to breathe. Signs of respiratory distress such as increased respiratory rate, use of accessory muscles, nasal flaring, retractions, restlessness, and confusion may occur. Early intubation is recommended for an extensive upper airway injury. Lower airway injury (damage to lung parenchyma) is caused by breathing in smoke and soot from the fire. This type of injury may also require intubation and ventilation and may be life threatening. Patients who should be watched closely for signs of developing respiratory problems include those who have: Burns of the face and neck Singed nasal hair or darkened membranes in the nose and mouth  Smoky-smelling breath Dark or black sputum Burning sensation in the throat or chest A history of having been burned in an enclosed space Watch for increasing restlessness, coughing, hoarseness, rapid shallow respirations, stridor (high-pitched musical sound on inspiration), and falling oxygen saturation (below 95%). Humidified oxygen is given if the patient is experiencing respiratory distress, and bronchodilators may be given; intubation and mechanical ventilation may be required. Keep necessary equipment at hand and constantly assess the patient’s respiratory effort. Use an incentive spirometer, coughing, turning, and early ambulation to maintain good respiratory function. Ongoing respiratory therapy treatments may be ordered. Fluid resuscitation and prevention of shock A major concern in the care of a burn victim is to prevent shock from circulatory collapse. The two most important measures used to relieve profound shock in a burn patient are: Replacement of lost fluids and electrolytes (fluid resuscitation) Enhancement of tissue perfusion The loss of fluids and electrolytes results from the sudden capillary leak and shifting of the blood plasma and tissue fluids from their normal site to the area of the burn. This shift occurs in the first 24 to 48 hours after the burn. The fluids are then lost by movement from the vascular space to the interstitial spaces. Fluid resuscitation needs are based on one of several burn formulas. The Parkland formula for fluid resuscitation is: 4 mL Ringer’s lactate (RL) × % burn × weight in kg One-half of the required fluid should be given within 8 hours of the time of the burn. The second half is given over the next 16 hours. After that, fluids are based on specific volume and electrolyte imbalances and response to treatment. Fluid replacement is calculated from the time of injury, not from the time of arrival at the medical facility. Important nursing functions are to keep IV access sites patent and secured in place and to ensure that the fluids are administered at the ordered rates. Unless fluids are replaced immediately, the cardiac output will drop, and the resultant profound shock may be fatal to the patient. The patient’s vital signs must be checked hourly and recorded accurately. A blood pressure reading taken by cuff from an extremity may not be reliable. An arterial line may be inserted for more accurate monitoring of blood pressure changes. The state of sensorium or level of consciousness is another key observation in the assessment of tissue perfusion. Constantly assess the patient’s level of alertness and clarity of thinking, asking the patient who they are, where they are, their age, what happened, and so on. There are significant dangers to fluid resuscitation; for example, excessive fluid potentiates adult respiratory distress syndrome, and extreme fluid deficit will cause acute renal failure. It is very important to monitor the signs of adequate fluid resuscitation and know when to increase or decrease the fluids based on clinical findings. After the first 24 hours, 5% dextrose in water (D5W) is given to maintain a serum sodium level of 135 to 145 mEq/L. Fluid intake and output and daily weights are measured for as long as the patient has open wounds. Laboratory data are checked frequently for evidence of either a deficit or a surplus of specific electrolytes. Pain management As soon as IV lines are established and fluid resuscitation is begun, pain control can begin. Measures to relieve pain include the administration of IV morphine or hydromorphone hydrochloride (Dilaudid). Doses of IV morphine may be higher than you are accustomed to seeing: 2 to 4 mg every 5 to 10 minutes is the standard starting dose, and the patient may require a much larger total dose because of the severe pain (Rice & Orgill, 2020). Fentanyl is another powerful opioid medication that can be combined with a benzodiazepine, such as midazolam, before painful wound care procedures. Ketamine and propofol are anesthetic agents that are used for control of pain during procedures. The massive fluid shifts that occur after a burn injury make absorption from an intramuscular site unpredictable in the first 24 hours after the burn. For chronic pain, gabapentin and methadone can be prescribed. Nonsteroidal antiinflammatory drugs (NSAIDs) work to control pain but may not be used if ongoing grafting is necessary or because of stress ulcers. Gastrointestinal management To prevent gastric distention secondary to mesenteric vasoconstriction, a nasogastric (NG) tube may be placed. Within 24 hours of injury, tube feedings may be initiated to help provide needed nutrients for healing and to counter the hypermetabolic burn response. Some patients may require medications to reduce gastric acid to prevent ulceration (Curling ulcer). Acute Phase of Burns The acute phase extends from the time of fluid mobilization and diuresis to when the burned area is completely covered by skin grafts or when burns are healed. Goals during this phase include management of pain and anxiety, prevention of wound infection, promotion of nutritional intake, and rehabilitation therapy. Prevention of infection Although wound infection is no longer the major cause of death in burn victims (the main cause of death is pneumonia), its prevention is important to recovery. Today patients are taken to the operating room very early after the burn. Burn eschar is excised away from the wound, and the area is covered with a biologic or biosynthetic skin. During the granulation stage of repair, the wound should look slightly pink and somewhat shiny. Healthy granulation tissue does not emit exudates. A very wet wound that has a foul odor indicates infection. A greenish blue wound exudate is a sign of Pseudomonas infection. Signs of inflammation, such as redness and swelling of the tissues adjacent to the wound, may indicate cellulitis (acute inflammation of the subcutaneous tissues). Signs of infection should be reported to the health care provider. If wound sepsis occurs, IV antibiotics specific to bacteria in the wound are given and topical antibacterial soaks are applied to the wound. Critically burned patients have a high risk for pneumonia. Pneumonia in hospitalized patients may be ventilator-associated hospital-acquired pneumonia (V-HAP) or nonventilator hospital- acquired pneumonia (NV-HAP). Burn patients were at higher risk for either type of pneumonia than similar patients who did not have burns. The addition of inhalation injury puts the patient at further risk (Jeschke et al., 2020). Examples of Core Measures for patients in intensive care units (ICUs) include protocols to prevent deep vein thrombosis and ventilator-associated pneumonia. Wound treatment General principles for the care of burn wounds include keeping the subendothelial layers moist, preventing infection, promoting healing, and minimizing pain. Antimicrobial ointments are used topically to prevent colonization of the wound. Superficial burns may then be covered with a nonadherent dressing, such as Xeroform, Adaptic, or Mepitel. Most burns have several thicknesses of burn, are not uniform, and may require different dressings. If healing tissues are normally in a moist environment, they will heal best if kept moist and not allowed to dry out. Surface skin that is normally dry should be allowed to dry for healing. Deep wounds will need surgical debridement and graft or flap coverage. If surgical intervention has not yet occurred, silver-containing dressings or ointments may be used to keep the wound moist and the dressing nonadherent. If the tissue is not ready for a skin graft but has been surgically cleaned, dressings with allografts, biologics, and biosynthetic coverings may be used (Tenenhaus & Rennekampff, 2020). Burn wounds are cleansed with sterile saline using sterile technique at least once daily. Prior to wound care, analgesics should be given. The goal is to remove excess exudate and drainage and to minimize the danger of infection. Wounds of the face or ears are left undressed. After the wounds are cleaned, a topical ointment such as bacitracin is usually applied every 8 hours to prevent infection and promote healing. Burns on the hands, extremities, or trunk may be cleansed at the bedside, on a shower table in the burn unit treatment room, or in a whirlpool bath. Cleansing is done at least once a day, and these wounds are dressed. Dressings are composed of layers of sterile gauze saturated with topical medications, biologic dressings, synthetic dressings, or artificial skin. The wound is then wrapped with stretch gauze, such as Kling, or with elastic mesh webbing. Table 43.4 lists the most common topical medications and their nursing implications. Escharotomy Eschar is a source of infection, and it impairs healing. Removal of eschar and necrotic skin (debridement) is usually done within 24 to 72 hours after the burn (Fig. 43.16) as long as the patient is stable enough to tolerate general anesthesia. If removal of eschar is not possible, tissue perfusion or quality of respiration can become compromised because of circumferential eschar constriction, and escharotomy is performed. An incision into the burn eschar with a scalpel or electrocautery relieves pressure caused by circumferential burns that encircle an extremity or that constrict movement of the chest. The incisions extend into the subcutaneous tissue. If the pressure is not relieved, arterial blood flow in the extremity will be compromised, possibly causing necrosis; nerve damage from the pressure also may occur. An escharotomy on the chest improves lung expansion and oxygenation. The procedure does not cause discomfort because the nerve endings have been destroyed by the burn. No anesthesia is required. Early removal of eschar and necrotic tissue is the goal and prevents complications of eschar constriction. Be alert for compartment syndrome, which occurs when increased pressure within a compartment (e.g., arm, leg) causes compromise of circulation to the area. Fluid accumulation from edema can cause compartment syndrome in burn patients. Monitor for increasing pain, paleness and tenseness of the tissue, numbness or tingling, discoloration in the distal portion of the extremity, and decreased sensation (paresthesia). Debridement Debridement may need to be an ongoing process as the full depth of the burn is realized. Mechanical techniques such as soap and water, moistened gauze, or chlorhexidine surgical scrub brushes may be used if irrigation with sterile saline is ineffective in removing dead tissue. Proteolytic enzymes may also be applied to chemically debride the wound. New tissue growth is promoted with a clean wound bed and moist sterile environment. Large wound debridement is done in the operating room. Grafting Surgical removal of eschar and applications of biologic dressings are done within the first few hours after the burn injury. Biologic dressings are materials obtained from cadavers or from animals. It is most desirable to graft the patient’s own skin (autograft), but when this is not possible, a homograft (the skin of another person [allograft], obtained from a cadaver), a heterograft (xenograft, usually obtained from a pig), or artificial (biosynthetic) skin, such as Biobrane, can be used as a temporary measure. Biobrane is a nylon fabric with a silicone film that allows exudate to pass through. The many synthetic dressings available consist of silicone, plastics, or alginate (brown seaweed combined with other substances) and remain in place for 1 to 14 days. The patient’s own skin is the only permanent graft material. Some success has been achieved in growing skin cells harvested from the patient in cultures, but this is a slow, expensive process. The epithelial sheets grown are then used for grafting. When autografting is performed, there is a donor site from which a split-thickness piece of skin has been removed. That piece of skin may be used intact, or it may be cut into a mesh pattern (Fig. 43.17). It takes longer for a mesh graft area to heal because the skin cells need to grow into the holes between the links of skin. Artiss is a fibrin sealant used for adhering skin grafts for burn patients. Recovery time from a split-thickness skin graft is rapid, commonly less than 3 weeks (Gardner, 2020). Donor sites may be covered by a film dressing to hasten healing and decrease pain. The donor site is often more painful than the graft site. Once the donor site has healed completely, skin may be harvested from that site again. Pressure dressings are worn as soon as grafts heal to decrease scarring that can inhibit mobility. The pressure dressing may be an elastic wrap or a custom-fitted, elasticized piece of clothing that provides uniform pressure over the burned area (Fig. 43.18). These pressure dressings must be worn 23 hours a day, every day, until the scar tissue is mature. Scar maturity takes 12 to 24 months. Daily exercise and splint applications are used to prevent contracture formation. After burns are fully healed and the scar tissue has matured, plastic surgery may be performed to try to rebuild lost structures, such as the nose or an ear, or to enhance appearance. Complications When a sizable burn occurs, blood flow is shifted to the brain, heart, and liver because of the fluid changes that occur. The gastrointestinal tract receives decreased blood, and gastric motility is impaired. Monitor peristalsis and be alert to signs of paralytic ileus. Severe abdominal distention may occur. A Curling ulcer may develop, inducing gastrointestinal bleeding. Stools are monitored for signs of occult blood. A histamine (H2)-receptor antagonist, such as cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), or nizatidine (Axid), may be administered IV to prevent this complication. Contractures always are a threat with major burns and sometimes with minor burns. Proper positioning and regular exercise are essential to prevent musculoskeletal deformities after a burn. Although the motion of physical therapy exercises may be painful, the muscles and skin must be exercised and stretched every day for normal motion to be maintained. Sometimes it is necessary for the patient to continue visiting the physical therapist for several months after discharge from the hospital. Ambulation two or three times a day is begun as soon as the fluid shift has stabilized for patients who have no fractures or serious injuries to the feet or legs. Rehabilitation Phase of Burns A patient who has experienced a major burn is transferred to a rehabilitation facility. The rehabilitation phase begins with wound closure and ends when the patient reaches the highest level of function possible. This phase may last for years. The phases of burn rehabilitation have been referred to as the first 2 minutes, the first 2 hours, the first 2 days, the first 2 weeks, the first 2 months, and the first 2 years. Continued physical therapy and psychological care are essential to help the patient achieve their optimal level of function. Some patients must learn to use adaptive devices or alter the way they formerly accomplished tasks. When the patient is ready and able to accept some responsibility for self-care, preparation for release from the hospital begins. Teach the patient how to apply topical agents without contaminating the wound and how to change dressings if these are used. A family member, if available, is included in burn care education. Maturing scars usually appear red, hard, and raised before they eventually begin to fade and soften. Pressure garments and masks help prevent thick and disfiguring scars but are uncomfortable. The patient may resist wearing them unless there is understanding of their intended purpose. Your encouragement and reinforcement of the purpose can help. Reintegration into roles, community activities, and employment takes time. Participation in a support group of burn victims is sometimes helpful. In this way the patient and family realize that they are not alone in their struggles with the many problems that the injury has brought. Assessment of the home environment and family interaction is essential before discharge. Knowing how the patient formerly coped with stressful situations helps the professional personnel involved support that patient. Having friends visit and making short trips out in public is helpful in dealing with the reactions of others to burn scars and disfigurement. Referral for job retraining may be required if the patient will be unable to return to a former occupation because of residual physical deficits. See Chapter 9 for rehabilitation goals and principles. Nursing Management Care of a burn patient is interdisciplinary and includes the services of the health care provider, surgeon, nurses, dietitian, respiratory therapist, physical therapist, occupational therapist, psychologist or psychiatrist, and social worker. Other health professionals are added to the team as needed. Collaborative planning meetings are scheduled at least once a week initially. Input for the plan of care is contributed by all members of the team. Assessment (Data Collection) A thorough assessment of all body systems and psychological response is performed on admission and continues throughout because of the potential for complications. The patient’s vital signs and pain level must be checked and recorded at regular intervals. The condition of the wounds also should be assessed systematically to determine whether healing is taking place as it should and infection is being prevented. Wounds are carefully assessed at each dressing change. Signs that indicate infection include the following: Strong odor Color change to dark red or brown Redness around edges extending to unburned skin Texture change Exudate and purulent drainage Sloughing of graft Such signs should be reported because a culture or biopsy should be performed. Think Critically What would you do if, when taking vital signs, you find that the pulse on the burned arm is weaker than that on the other, unburned extremity? Problem Statement/Nursing Diagnosis Care of a burn patient is extremely complex. The plan of care must be frequently revised and updated. Problem statements or nursing diagnoses commonly used for burn patients are included in Nursing Care Plan 43.1. Additional problem statements include the following: Altered nutrition due to increased caloric demands and inability to orally ingest sufficient calories. Anxiety due to pain, guilt associated with injury, financial concerns, appearance, treatment, and prognosis. Altered body image due to disfigurement secondary to burn injury. Altered family coping due to alteration in roles. Insufficient knowledge due to home care. Planning Examples of appropriate expected outcomes are written for the individual patient, such as the following: Patient will regain nutritional balance by no further weight loss and signs of wound healing. Patient will state that there is a decrease in anxiety. Patient will integrate the altered body image by expressing positive statements regarding their appearance. Patient will demonstrate new coping mechanisms.  Family will state ways in which they are coping with caring for patient at home. Patient and family will learn to provide good care at home evidenced by continued recovery without complications. Implementation Managing Pain Use gentleness and care in handling the patient as they are turned or treatment is administered. This reduces the amount of pain, and the less the patient is handled, the less danger there is of contaminating the wounds. Despite advances in burn care, research studies show that pain continues to be undertreated, and even experienced clinicians tend to overestimate the efficacy of opioids. Morphine or hydromorphone hydrochloride should be administered with a patient- controlled analgesia pump when possible. Boluses are necessary before treatments or surgical procedures and at bedtime. Antianxiety agents such as lorazepam (Ativan) or antipsychotics such as haloperidol (Haldol) or quetiapine (Seroquel) should be used along with analgesia. Burn pain can be distressful for years after the burn occurs (Wiechman & Sharar, 2020). Pain continues even after the wound appears to have healed completely. Exercises to prevent contractures can cause pain because they stretch the skin while it is very tender. Splints to prevent musculoskeletal complications can also cause discomfort. Analgesics will allow the patient to get sufficient rest, but they should be given judiciously as the pain becomes less acute. If a patient begins to depend too much on one kind of analgesic, alternative drugs should be given. Nursing Care Plan 43.1 Care of a Patient With a Burn ADLs, Activities of daily living; bid, twice a day; IV, intravenous; PCA, patient-controlled analgesia; PT, physical therapy; WBC, white blood cell. Scenario Mr. Young, age 33 years, sustained partial- and full-thickness burns over both legs when a container of gasoline he was carrying ignited and he dropped it, splashing it onto his legs. In the emergency department, his wounds were cleaned and a topical agent was applied; no dressings were applied. Intravenous lines were established, and fluids were administered to prevent potential fluid and electrolyte imbalance. He received morphine for pain and on admission to the unit was fairly comfortable, conscious, and oriented. He is in the emergent phase. Problem Statement/Nursing Diagnosis Fluid volume deficit related to fluid shift and loss of fluids via open burn wounds. Supporting Assessment Data Objective: Partial-thickness burns and full-thickness burns on legs; burn areas becoming edematous. Preventing Infection An aseptic environment is needed for burn care. Stringent cleaning standards must be implemented and monitored. Standard Precautions are used for all burn care, and private rooms are recommended. Meticulous hand hygiene is essential. Those in attendance wear caps, gowns, and gloves while caring for the patient as a protective measure. Contact precautions are used for infected wounds. Gloves are worn for all contact with open wounds and are changed when handling wounds on different areas of the patient’s body and between handling soiled and sterile dressings. Hand hygiene is performed between glove changes. Patient care items are not shared, and great attention is paid to maintaining asepsis for all patient care. Bed linens are changed daily and whenever soiled, and a bed cradle or some other device is used to support the weight of the top covers to keep them off the burned areas. Managing Itch Multiple layers of tissue are involved in a deep burn. The treatment of postburn itch is a complex issue requiring trial of various treatments. Oral antihistamines are effective in many patients. Nonpharmacologic measures to reduce itching, such as massage, transcutaneous electrical nerve stimulation (TENS), music therapy, and botulinum toxin, are used along with medication such as gabapentin. Therapeutic touch may prove helpful. Acupressure and acupuncture may assist with pain and itch relief. Topical antihistamines or local anesthetics have also shown effectiveness (Wiechman & Sharar, 2020). Nutritional Support Enteral feedings are started within 24 to 28 hours after injury. Early feeding helps prevent ileus and provides needed nutrients. If enteral feedings are not tolerated, parenteral nutrition is provided. A diet high in protein and calories is necessary for healing. The patient has increased metabolic needs directly proportional to the size of the burn area. Nutritional needs may be increased 50% to 150% above normal, and increased requirements can continue for 9 to 12 months. Caloric needs are calculated to include the patient’s weight, age, and percentage of burn over total body surface as well as presumed energy requirements (Romanowski, 2020). Only high- calorie liquids are given to drink. Free water intake is restricted. Dietary supplements include vitamins, especially vitamins A, C, and D. Minerals such as zinc and copper are supplied because deficiencies are seen in burn patients. Consultation with a nutritionist is essential because of the dietary issues that can occur for burn patients. There appears to be a maximum glucose load, and high carbohydrate intake can lead to hyperglycemia, dehydration, and respiratory problems. Excessive lipid intake has been associated with impaired wound healing, and ability to tolerate protein is related to renal function and fluid balance. Complementary and Alternative Therapies Helping Burn Patients Relax It was found that the use of immersive virtual reality in the form of video games was effective in reducing anxiety and pain in burn patients (Bermo et al., 2020). Psychosocial Support Burn patients may face loss of mobility and independence or disfigurement involving the face or other parts of the body usually visible to others. Many experience post-traumatic stress syndrome, and others may feel guilt, anger, or depression. Strive to develop an attitude of acceptance of the patient, a calm approach to dressing changes and discussions of scar formation, and an optimistic emphasis on what the patient can do and will be able to do in the future. When a patient has difficulty coping with the physical and psychosocial effects of a severe burn, effective nursing intervention can help the patient deal with their fears, anxieties, and sense of loss. Facility chaplains, counselors, social workers, and other team members can help the patient work through feelings. Assist the patient through the grief process and encourage them to relate what is experienced and their feelings about what has happened or is happening. Encourage the patient to ask questions and to verbalize their concerns about the care and the treatment plan. You can reinforce the patient’s self-esteem by emphasizing the strengths you have noticed when the patient was coping with pain, inconvenience, or some other unpleasant situation. Involving the patient in performing self-care as much as possible and giving some sense of control over the situation are helpful. Clinical psychologists and psychiatrists may be needed if progress is not made. The patient’s body image may have been severely disrupted. Assist the patient to grieve over the loss and integrate the present body image. If the burns were caused by a suicide attempt or a risky behavior, psychiatric therapy will probably be necessary to deal with feelings of guilt. Although males and children younger than 4 years are more