Adult Health Integumentary PDF

Chapter 43 Adult Health Nursing Concepts and Clinical  Ask the patient about recent skin lesions or rashes  Where the lesions first appeared  How long the lesions have been present?  c/o pain? Pruritis? Tingling? Burning?  Any recent skin color changes?  Exposure to sun with or without sun...

Chapter 43 Adult Health Nursing Concepts and Clinical  Ask the patient about recent skin lesions or rashes  Where the lesions first appeared  How long the lesions have been present?  c/o pain? Pruritis? Tingling? Burning?  Any recent skin color changes?  Exposure to sun with or without sun screen?  Family history of skin cancer?  See pages 1302-1307 for skin lesions  The degree of color of a dark skinned person is genetically determined.  Increased melanin. Forms a sun shield for dark skin and results in decreased incidence of skin cancer.  Assessment of skin color is easier in areas where the skin is lighter, such as palms, soles of feet underside of forearms, abdomen, buttocks  Assess pallor in lips and mucous membranes, nailbeds, conjunctiva.  Rashes are difficult to observe and may need to be palpated.  Document exact location, length, width, general appearance and type  Mnemonic PQRST  Provacative and Palliative factors (what caused the condition)  Quality and quantity (characteristics and size)  Region of the body  Severity of the signs and symptoms  Time (length of time the client has had the disorder)  A – is the mole Asymmetric?  B – are the Borders irregular?  C – is the Color uneven or irregular  D – has the Diameter of the growth changed recently  E – has the surface area become Elevated or is it Evolving  Stage 1 – Non-blanchable erythema of intact skin  Stage 2 – Partial thickness skin loss of dermis. Ulcer is superficial and manifests clinically as an abrasion, blister, or shallow crater.  Terms:  Eschar  Slough  Granulation  Epithelialization  Undermining  Tunneling  Stage 3 – Full thickness skin loss involves damage or necrosis of subcutaneous tissue but bone, tendon, and muscle are not exposed. Ulcer manifests clinically as a deep crater with or without undermining or tunneling of adjacent tissue  Stage 4 – Full thickness skin loss occurs with exposed cartilage, bone, tendon or muscle, tissue necrosis (slough/eschar). Often includes undermining and tunneling. Risk for osteomyelitis  Unstageable – full thickness tissue loss, a wound base covered by slough (yellow, tan, gray, green, or brown), and/or eschar in wound bed.  It is not possible to determine the depth and stage of the ulcer until base of wound has been exposed.  Stable eschar on the heels provides a natural biologic cover and shouldn’t be removed.  Suspected deep tissue injury – localized purple or maroon intact skin or blood filled blister.  Painful, firm, mushy, boggy, or warm to cool compared to adjacent tissue  With dark skin tones, deep tissue injury is difficult to detect but often starts with blister over dark wound bed.  Can evolve rapidly  Type 1 is characterized by a vesicle at the corner of the mouth, on the lips, or on the nose. (cold sore or fever blister)  Subjective data – c/o fatigue, pruritus in mouth  Objective data – edematous, erythematous area at corner of lip appears first.  The vesicles then appears, ulcerates, and encrusts.  The vesicular lesions may rupture and develop a dried exudate.  When it ruptures there is a burning pain felt.  Type 2 causes lesions in the genital area or rectal area and is known as genital herpes.  Type 2 transmission is primarily through sexual contact.  Produces various types of vesicles that rupture and encrust, causing ulcerations.  Subjective data – c/o fatigue, pruritus in or genital area, and complaints of burning in area involved.  Objective data –Type 2 the labia, vulva, or penis will appear edematous and erythematous.  Vesicular lesions may rupture developing dried exudate.  Lymph nodes may be tender and enlarged  Transmission of both may occur by direct contact with any open lesion.  Lesions are most painful during first week.  Usual occurrence is during an acute illness or infection  Severe consequences in pregnancy  Diagnosis  Cultures from the lesion.  Diagnosis through cultures  No cure  Treatment is aimed at relieving symptoms.  Acyclovir is an antiviral that can alter the course of the disease. (oral, topical, IV)  Warm compresses can be used to relieve pain and severe pruritus.  Keep lesions dry and avoid direct contact  Analgesics are effective. (Tylenol)  Teach prevention of spreading.  Type 1: herpes simplex; healing within 10-14 days. May reoccur with depression of the immune system.  Type 2: genital herpes; lesions usually present 7-14 days. Approximately 2/3 will have 1-5 recurrences annually.  Triggers: fatigue, illness, emotional distress, HSV2 genital irritation  Myth. 1. Now that I have genital herpes, I should never have sex again. Fact: You can still have sex if you have genital herpes. (Please do!) It is, however, important to avoid sexual contact if you have any symptoms, or oral or genital sores.  Also, due to asymptomatic viral shedding (you don't have any signs or symptoms but the virus is present on the skin), you could still be contagious even though sores are not present.  You should always use safer sex barriers even when you are asymptomatic.  It is important to note, too, that the virus can be transmitted orally, to the genitals, during oral sex. Valtrex (an antiviral drug used to treat herpes) was found to help reduce the risk of transmission.  Myth. 2. Cold sores aren’t associated with genital herpes. Fact: Cold sores are caused by herpes simplex virus type 1. If you have oral-genital sex with someone who has a cold sore, this virus can give you genital herpes. The likelihood of this is particularly high during a primary outbreak. Washing with soap and water after a sexual encounter can help decrease the risk of this type of transmission.  Myth. 3. You can contract genital herpes from toilet seats. Fact: The genital herpes virus dries out when it is exposed to air, and is quite fragile. There have been no proven cases of genital herpes transmission from a toilet seat.  Caused by same virus that causes chickenpox  Virus lies dormant in patients until their resistance to infection has been lowered.  Lesions are located along nerve fibers of spinal ganglia. (dorsal root ganglia)  At the skin surface the virus multiplies and forms an erythematous rash of small vesicles along a spinal nerve pathway.  Eruption of vesicles is preceded by severe pain  Generally occurs in the thoracic region  Can affect lumbar, cervical, or cranial nerves. Evidence of skin excoriation related to scratching Frequent requests for analgesics  Eruption occurs along the nerve involved  Vesicles rupture and form a crust. The serous fluid may become purulent.  The course of this painful condition is from 7-28 days.  Pain is severe (burning and knifelike) usually on one side  Pruritis  General malaise  History of Chickenpox  Stay away from pregnant women and immunocompromised clients  Skin excoriation  Patches of vesicles on erythematous skin following peripheral nerve pathway  Demonstration of tenderness to touch to involved area  Frequent requests for analgesics  Diagnosis is through a culture, physical exam and health history  Control the pain, pruritis and prevent secondary complications.  Steroids for inflammation and edema - corticosteroids  Oral and IV acyclovir reduces the pain and duration of virus.  Lotions for pruritus –medicated baths, topical corticosteroids  Recovery is 2-3 weeks  20% experience some neuralgia after shingles  Aseptic technique  Teaching prevention of spread and infection  Shingrix is preferred vaccine; most effective; 50 years and older  Zostavax-a vaccine to prevent herpes zoster is recommended for adults over 60 who have had chickenpox  Older pts are more susceptible to complications such as post therapy neuralgia.  Can result in eye complications  Virus remains latent in body  Another person who has not had chickenpox or is immunocompromised can get chickenpox from someone who has shingles.  Usually good  Infection of the skin  Not contagious, but can be spread by direct contact with an open area on a person that has an infection  Strep and Staph  Bacteria enter the body through break in skin  Usually superficial, but can spread into deeper tissues and bloodstream causing sepsis.  Develops as an edematous, erythematous area of skin that feels hot and tender  Caused by staphylococcus aureus or strep generally  Get it at any age by most commonly seen in children  Lesions start as macules that develop into pustulant vesicles that rupture and form a dried exudate.  Crust is honey colored and easily removed. Smooth, red skin under crust  Face, hands, arms, and legs most often  Exudate pinpoint in size to nickel or larger  Highly contagious inflammatory disorder  May be spread by touching exudate, personal articles, linens, and clothing of infected person  Subjective  Objective  Pruritus  Erythema  Pruritic areas  Pain  Honey-colored  Malaise crust over dried  Spreading of lesions disease to different  Smooth, red skin body parts under crust  Other diseases  Low-grade fever may be present  Leukocytosis  Positive culture  Purulent exudate  Systemic Antibiotics based on C&S (usually erythromycin, penicillin, or a cephalosporin)  Use of antiseptic soaps to remove crusted exudate (Betadine or Hibiclens)  Then apply antibiotic cream usually Bactroban  Prevention of glomerulonephritis is a primary goal post streptococcal infections  Gloves should be used  Topical antibiotics are applied several times a day using sterile technique.  Teach regarding prevention of spreading disease, and taking all antibiotics  Tinea Capitis  Tinea Corporis  Tinea Cruris  Tinea Pedis  Use of topical or oral antifungal drugs. (Oral - Griseofulvin ((Fulvicin, Grifulvin))  Topical drugs do not penetrate the hair bulb.  Antifungal soaps and shampoos are recommended.  Tolnaftate 1% (Tinactin, clotrimazole (Lotrimin AF), or Desenex can be applied directly  Treatment can last from 2-6 weeks.  Protect the involved area from trauma and irritation by keeping it clean and dry  Proper application of medications and warm compresses to alleviate the fungus.  Tinea pedis pts should be taught to wear sandal-type shoes or absorbent materialed foot wear to decrease moisture. Also stress excellent foot care especially between the toes.  Caused by direct contact with agents in the environment to which a person is hypersensitive.  First erythema and edema, then vesicles form that rupture and encrust  Pruritis that leads to further excoriation  Epidermis becomes inflamed and damaged by repeated contact with physical and chemical irritants.  Lesions at point of contact  Subjective Data  Objective – New soap – Erythema – Traveling using – Papules and different personal vesicles appearing items most often on – Working with plants dorsal surfaces or flowers – Vesicles that ooze – Severe pruritus, – Scratch marks burning, pain – Edema of area – Difficulty moving the involved area  Try to determine cause  Symptomatic treatment  Corticosteroids  Antihistamines (diphenhydramine)  If client has asthma monitor for asthma attack; may require treatment  Discover cause of hypersensitivity. Teach to keep an accurate history of possible predisposing offensive agents  Wet dressing, using Burrow’s solution  Aseptic technique  Cool environment with increased humidity  Cold compresses to decrease circulation  Daily baths to cleanse the skin  Cut fingernails to decrease scratching  Clothing lightweight and loose to decrease trauma and allow air circulation  Teach to identify irritant and avoid it  Topical creams can be used per PCP instruction  Dermatitis Venenata – results from contact with certain plants (poison ivy or poison oak)  S/S mild to severe erythema with pruritus. – First exposure the body undergoes a sensitizing antigen formation. – Subsequent exposure to antigen causes the lymphocytes to release irritating chemicals, leading to inflammation, edema, and vesiculation.  Found on body part exposed to agent  Corticosteroids  Occurs when a person is given a medication to which he is hypersensitive.  May cause severe respiratory arrest.  Need to identify the drug and discontinue it. (MD)  Notify MD  Lesions will disappear after medication is stopped.  Treatment is individualized  Definition is presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold.  Wheals are found with white in center and pale red periphery  Appear suddenly  Caused by release of histamine in an antigen- antibody reaction.  Meds – antihistamine and sometimes epinephrine  Form of urticaria (causes are the same)  Occurs in the subcutaneous tissue  Characterized by local edema of an entire area, such as eyelid, hands, feet, tongue, larynx, GI tract, genitalia or lips.  Single edematous area appears at one time  Antihistamines, epinephrine, or corticosteroids such as Solu-Medrol  Cold pack or cold compress may be used  Can cause respiratory distress if in throat  S/S of anaphylactic reaction (SOB, Wheezing, Cyanosis)  Chronic inflammatory disorder of the skin  Primarily a disease beginning in infancy  Associated with allergies to chocolate, eggs, wheat, and OJ  Asthma may be associated with children who have eczema  Heredity is a factor  Medical Management is concerned with decreasing the amount of allergen exposure  Papular and vesicular lesions appear and are surrounded by erythema  Post vesicular rupture, they dc a yellow exudate that dries and encrusts.  Primary sign is pruritus and sensitive skin  Children are more fussy and irritable, anorexia is common  Vesicles and papules are found on scalp, forehead, cheeks, neck, and surface of extremities  Involved area is erythematous and dry.  Scales accompanied by dryness in the involved area provides a distinguishing characteristic of eczema  Primary goal is to break the inflammatory cycle  Hydration of the skin is key  Hydrate skin by soaking in warm water for 15- 20 minutes, pat dry, then apply an occlusive ointment to damp skin to retain water  Examples are petrolatum, corticosteroid ointments, and vegetable shortenings  Steroids decrease inflammation  When lesions begin to heal lotions (Eucerin, Lubriderm, Curel) should be applied tid or qid  Inflammatory papulopustular skin eruption that involves the sebaceous glands  Primarily in adolescents  Exact cause unknown  Risk factors – Diet (questionable) – Stress – Heredity – Overactive hormones – Grease and oil containing cosmetics – perspiration  Acne develops when oil glands become occluded.  Most often on face, neck, upper chest, shoulder, and back  First symptom is tenderness and edema, followed by comedo (blackhead)  Skin is oily and shiny, and lasts up to 10 days  Scarring results from large lesions that are traumatized when the individual tries to rupture the comedo  Involves topical, systemic, or intralesional medications  See Table 43.4 for meds to treat acne  Systemic antibiotic therapy, combined with topical therapy decreases scarring.  Some medications are harmful to fetuses  EX: Isotretinoin – changes in behavior, hepatotoxicity, assess for pregnancy as it is destructive to fetuses. requires liver function tests  Keep the skin clean and dry  Psychological concerns  Pt’s hands and hair should be kept away from face.  Clothes should not restrict affected areas  Hair should be washed daily  Skin should be washed 2-3 times a day with medicated soap  Cosmetics should be water based  3 weeks of treatment before improvement shows  Some low dose oral contraceptives may help  Non infectious skin d/o  Hereditary, chronic, proliferative disease involving the epidermis and can occur at any age.  Skin cells divide more rapidly than every 28 days. As soon as 7 days  Lesions are papular in primary stage  Papules become plaques located on the scalp, elbows, chin, and trunk  Red skin patches covered with silver scales  Topical steroids (hydrocortisone and betamethasone valerate) and keratolytic agents are used in occlusive wet dressings to decrease inflammation  Keratolytic agents such as tar preps and salicylic acid decrease shedding of outer layer of skin  Incurable but treatable  Photochemotherapy may be used. This involves a drug enhanced by exposure to light.  Methotrexate and vitamin D reduce epidermal proliferation in some cases. Also cyclosporine, acitretin  Infliximab biological to control severe plaque form of the disease  Affects the skin and may become systemic.  An inflammatory condition with skin manifestation describes discoid lupus that can lead to the autoimmune systemic lupus erythematous  SLE is an autoimmune disorder characterized by inflammation of almost any body part  The body produces antibodies against its own cells  Exacerbations and remissions that may be triggered by genetic, hormonal, and environmental factors  Affects several organ systems, skin, joints, kidneys, and serous membranes.  Chronic, incurable, and multi-causal disease  Unknown origin  Most prevalent in women of childbearing age  Genetic disposition  More in women than men (10%)  3x more African Americans as whites  Survival rates have increased longer than 15 years post diagnosis  Oral Ulcers  Peripheral neuropathies  Arthralgias  Anemia  Arthritis  Leukopenia  Vasculitis  Thrombocytopenia  Rash  Coagulopathies  Nephritis  Immunosuppression  Pericarditis  Dermatitis  Synovitis  Organic brain syndromes  Butterfly rash No single test is considered conclusive. 1 or more of the diagnostic tests along with at least three other criteria lead to diagnosis of SLE   Diagnostic Tests Criteria  Anti-nuclear antibody  Erythematous butterfly  DNA antibody rash  Anti-Sm antibody  Alopecia  Complement  Bullae, patchy areas of  CBC purpura, etc.   Photosensitivity Erythrocyte sedimentation rate  Oral ulcers  Coagulation profile  Polyarthralgias/  Rheumatoid factor polyarthritis  Rapid plasma reagin  Pleuretic pain, pleural  Skin and renal biopsy effusion, pericarditis,  vasculitis C-reactive protein  Renal d/o  Coomb’s test  Seizures (neuro signs)  Lupus erythematous cell  Hematologic d/o preparation   Immunlogic d/o U/A  Chest radiographic study  Positive ANA  Goals include relief of symptoms, attempts to induce remission of the disease, alleviation of exacerbations early, and prevention of untoward complications.  NSAIDS, ASA  Antimalarial drugs (requires eye exam ac and annually)  Plaquenil  Corticosteroids  Methylprednisolone (IV for peak) to achieve remission  Antineoplastic drugs to achieve remission  Antiinfective agents are used to treat and prevent infections  Peritoneal dialysis or hemodialysis if necessary  Analgesics  Diuretics  Skin care (avoidance of sunlight and sunscreen and protective clothing)  Balancing rest and activity  Assisting pt to recognize early signs of exacerbation  (fever, rash, cough, increasing muscle and joint pain)  Early recognition of s/s of infection  Stress reduction and management  Balanced nutrition and reduction of Na  Lice/parasitic disorder of skin that is usually associated with poor living conditions and poor personal hygiene (not always the case)  Transmitted by close contact with infected individuals or their personal items  Lice obtain their nutrition from blood of their victims  Can live 1 to 2 days w/o a blood source  Leave their nits (eggs) on skin surface attached to shaft of the hair  3 types  Pediculosis capitis  the head louse attaches itself to the hair shaft  lays 10 eggs per day  adult life span-30 days  The eggs can be seen best at back of neck as gray, shiny, oval bodies  Pediculosis corporis  the body louse is found around the neck, waist, and thighs  Generally found in seams of clothing  Severe pruritus and pinpoint hemorrhages are caused from the bites  Pubic louse  Does not resemble head or body louse  looks like a crab with sharp pincers that attach to the pubic hair  Transmission is through sexual contact, bed clothing, or bath towels  Kwell or RID is used in any area contaminated patient  Stress contamination by contact  Each family member should be assessed  Cool compresses and corticosteroid ointments  Furniture or non-washable materials with which the patient has come in contact should be cleaned to prevent re-infection (wrapped or bagged for a period of time to allow lice to die)  Bed linens should be washed in hot water and dried in dryer.  Stuffed animals can be placed in a hot dryer for a full cycle  Cause is female itch mite.  The mite penetrates the skin and makes a burrow.  Once under the skin, the mite lays eggs that mature and rise to the skin surface.  Transmitted by prolonged contact with infected area or individual  Overcrowded living conditions, poverty  Changing sexual behaviors  Causes wavy brown, threadlike lines on the body  Pruritus is severe, worse at night, and secondary infections are common  Common Locations: are hands, arms, body folds, and genitalia  Most common locations for RASH: webbing between fingers, wrists, elbows, arm pits, and waistline  Diagnosed by presenting symptoms w/confirmation by skin scraping  Treatment basically same as for pediculosis  Proper application of medications  Educate about transmission (pt and family)  Clothing, linens, and bath articles should be washed in hot water and dried in dryer  Keloids – overgrowth of collagenous scar tissue at the site of a wound of the skin. – Seen more in African American’s than whites – Collagen tissue becomes raised, hard, shiny – May be pink, red, or flesh colored – Anywhere injury to skin – Sternum, ears, neck, and arms are common locations – Treatment – corticosteroids injections and radiation, cryotherapy, laser surgery, and surgical excision – may recur and be larger than before  Group of blood vessels dilate and form a tumorlike mass. – Common angioma is a birthmark, such as the port-wine birthmark – Discoloration is not elevated and may be found on one side of the face or any part of the body – Treatment involves electrolysis or radiation – Spider angioma or telangiectasis can be associated with liver disease – Group of venous capillaries dilate and branch out like a spider web. They resolve as the disease improves  Benign, viral, warty skin lesion with a rough, papillomatous (nipple like) growth Single or in groups  Thought to be contagious  Common locations: hands, arms, and fingers  But can occur anywhere  Plantar wart develops on sole of foot and is extremely painful  Treatments include cauterization, solid carbon dioxide (ex. dry ice), liquid nitrogen, and preparations of salicylic acid  Nonvascular tumors, also called birthmarks.  Some may become malignant  The raised, black nevus is the most threatening and removal is recommended to prevent its becoming malignant.  Change in color, size, or texture, or any bleeding or pruritus of a nevus deserves investigation.  One type of skin cancer  Basal cell layer of the epidermis  Face and upper trunk (may not be noticed)  Metastasis is rare, but underlying tissue destruction can progress to include vital structures.  Scaly in appearance or a pearly papule with a central crater and waxy pearly border  Early detection and complete removal, outcome is favorable  May recur in 40-50% of patients  Arises in the epidermis  Cancerous neoplasm is a firm, nodular lesion topped with a crust or a central area of ulceration and indurated margins  Rapid invasion with metastasis by way of the lymphatic system occurs in 10% of patients.  Sun-exposed areas: head, neck, and lower lip are common places of occurrence; also areas of chronic irritation or injury  Cancerous neoplasm in which pigment cells invade the epidermis, dermis, and sometimes the subcutaneous tissue.  Most arise from melanocytes in the epidermis, but some may appear in pre- existing moles. Heredity is a factor, and any person who has a large number of moles with a variety of sizes and colors should be monitored.  Exposure to ultraviolet light, chronic skin irritation, family h/o unusual moles, family or personal h/o melanoma  Superficial spreading melanomas (most common)  Anywhere on body  Slightly elevated, irregularly shaped lesions in varying combination of hues; common colors are tan, brown, black, blue, gray, and pink  Lentigo Malignant melanomas  Usually on heads and necks of older adults  Tan, flat lesions that undergo changes in shape and size  Nodular melanomas  Appear as blueberry type growth, varying from blue-black to pink  Grow and metastasize faster than other types  Acral lentiginous melanomas  Areas not exposed to sun with no hair follicles  Common locations are hands, soles, and mucous membranes of dark-skinned people.  Greatest risk have fair complexions, blue eyes, red or blond hair, and freckles.  Diagnosis through biopsy  Treatment depends on level of invasion and thickness of melanoma, client’s age and general health  Wide surgical excision of primary lesion is the treatment of choice  May need skin graft  Nonspecific immunotherapy, chemotherapy, chemoimmunotherapy, radiation may be used  Pain relief  Reduction of anxiety  Discharge instructions  Wound care  Medication  Cleansing  Follow-up care  Protection of skin  Avoid sun exposure during peak hours 11-3  Wear light colored clothing, a hat, and sunglasses outside  Use sunscreens with appropriate SPF of at least 15. Reapply every 2 hours  Perform monthly skin self examinations  Report skin changes, moles, or suspicious lesions to provider immediately.  Key is thickness  Individuals with lesions less than 1 mm thick have a survival rate of almost 100%  Those with lesions 3 mm thick or thicker have survival rates of less than 50%  Metastasize by vascular or lymphatic spread, with rapid movement of melanoma cells to other parts of body.  Alopecia – loss of hair. Usually not permanent unless due to aging  Hypertrichosis (Hirsutism) –  excessive growth of hair in a masculine distribution  can be hereditary or acquired as result of hormone dysfunction and medication.  treatment is removal by dermabrasion, electrolysis, chemical depilation, shaving, tweezing, or rubbing with pumice  Hypotrichosis  absence of hair or a decrease in hair growth.  caused by skin disease, endocrine problems, or malnutrition  treatment involves determining cause and treating cause  Paronychia –  disorder of nails.  get soft or brittle, and the shape can change as they grow into the soft tissue (ingrown nails)  infection of the nail develops and spreads around the nail  involved nails become painful as the nail loosens and separates from the tissue  treatment is wet dressings or topical antibiotics may be used; sometimes I&D of infected area is used  Thermal burns result from: flames, scalds, and thermal energy. (Most Common)  Non-thermal burns result from: electricity, chemicals, and radiation.  Destruction depends on:  the burning agent  the temperature of the burning agent  condition of skin before injury  the duration of the person’s contact with the agent.  The effect of the burn depends on two factors:  the extent of the body surface burned  the depth of the burn injury  Documented as a percentage of body surface area burned or the extent of the total body surface area injured  Burns exceeding 20% TBSA result in massive evaporative water losses and fluid loss into the interstitial spaces. Depth depends on the layers of the skin involved.  Chemical burn: rinse skin with COOL water to remove all chemicals  Electrical burns:  have an entry and exit site.  usually result in cardiac arrest. Start CPR if no pulse.  Emergent Phase (onset-48 hrs)  Intermediate or acute phase (48-72 hrs)  Long Term Rehabilitation phase (burn tx begins until healed)  1. Stop, drop, and roll. Stop burn. Remove any burning clothing or shoes  No ice or cold water– will increase burn  2. Open airway (AB)  3. Control bleeding (C)  4. Remove all non-adherent clothing and jewelry  5. Cover with sheet or cloth  6. Transport to hospital  In the damaged area the capillaries dilate, resulting in capillary hyper-permeability that lasts for about 24 hours.  Fluids shift from capillaries into the surrounding tissues, resulting in edema and blistering.  The larger the burn area involved, the greater the shift of fluid, resulting in a rapid shift of fluid from the intravascular area into the interstitial area (third spacing)  This shift causes the greatest threat to life because the cells become dehydrated. The body then goes into hypovolemic shock and hyperviscosity.  The BP drops, and the blood flow to the kidneys decreases, increasing chance of acute renal failure  H&H elevated, sodium – decreased, r/t third spacing, potassium – increased r/t cell destruction  1. airway  02; possible endotracheal tube  2. Fluid therapy  LR based on weight and TBSA burned  3. Urinary catheter for hourly urinary output  IV adjusted to maintain 30-50 ml urine per hour  4. NG tube  for prevention of aspiration r/t paralytic ileus  5. Pain meds  Small frequent doses  6. Give tetanus immunization  if not up to date in last 5 years.  Make take several hours to occur  Damage to cilia and mucosa of respiratory tract  Burns to closed or confined area  Anyone with burns to upper chest, neck, face is considered high risk for resp involvement.  Other s/s: singed nasal/facial hairs, soot in throat, hoarseness, stridor, sooty sputum.  Productive cough, singed nasal hairs  Agitation, tachypnea, flaring nostrils, intercostal retractions  Brassy cough, grunting or guttural respiratory sounds  Erythema or edema of oropharynx or nasopharynx  Carbon monoxide poisoning if in enclosed area.  CO displaces oxygen from hemoglobin  Don’t rely on pulse oximetry  s/s HA, NV, unsteady gait  Tx: 100% oxygen  Fluids shift back to intravascular space.  Usually 48-72 hrs after burn  Increase in cardiac output and renal perfusion, leads to diuresis  May last 10 days to months  Metabolism increases, urinary output increases which decreases fluid in interstitial tissue  Monitor VS, urinary output, level of consciousness  Two primary treatment goals of this phase:  treatment of burn wound  prevention and management of complications.  Infection is major complication after 72 hours  Superficial thickness injuries  Partial-thickness injuries  Full-thickness injuries See page 1338, Table 43-5.  Determines the total body surface area burned.  Head is 9%(4.5% each side)  Anterior and posterior aspects of the arms are 9% total (4.5% each side)  Legs are 9% anterior, 9% posterior  Chest and back are 18% each  Perineum 1%  Not accurate for children  (doesn’t take into account different levels of growth)  Priority is ABC  Respiratory pattern  Vital Signs  Circulation (hypovolemia, decreased cardiac output, edema, third spacing)  Intake and output/fluid status (weigh to determine fluid amount needed)  Bowel sounds  Stool and emesis for evidence of bleeding.  Inspection of the wound  Mental status in head-to-toe assessment  Monitor for s/s of acute renal failure (BUN/Cr)  Heart failure  Prevent infection – most common complication after 72 hours – Full protective isolation gear – Sterile technique with wound care  Nutritional Assessment  Daily weight, lytes, albumin, and UA  Psychological  Eschar must be removed. It is a black leathery crust that the body forms over burned tissue; eschar can harbor microorganisms and cause infection.  If a wound culture is to be taken, then you need to get it after removing eschar.  Can also cause circulatory constriction  Daily debridement and cleansing support regeneration – Give pain meds 30 minutes prior to debridement – Topical antibiotics post debridement and change dressings BID – Silvedine, sulfamylon, silver nitrate commonly used  New tx: Temporary skin substitute: faster healing, less scarring, avoiding painful dressing changes  Hydrotherapy softens eschar.  ROM and proper positioning for prevention of contractures  Autograft – comes from another part of body.  Homograft – another person or cadaver tissue  Heterograft – another species such as pig or cow  Synthetic graft substitutes are available  Needs as little movement as possible  Donor site care  Should eat by mouth ASAP  Increased caloric and protein requirements  2000-6000 calories a day  High calories offered often  Needs A, B, and C vitamins for digestion, absorption, and repair  Calcium, zinc, mag, and iron  Increase or achieve independence  Mobility is a major concern  Psychosocial of changed image  Box 43.8 page 1344  Patient teaching found in home care considerations page 1344