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I. NCLEX Tips ○ Priority intervention for a client with altered skin integrity is to institute measures to prevent infection bc integumentary system is the first line of defense ○ Priority psychosocial issue is body image disturbance ○ Many integumentary disorders can cause pruritus, and the nurse needs to institute measures that will relieve the discomfort associated with pruritus and teach the client about the importance of avoiding scratching the skin II. Wound Healing by Intention ○ First intention ○ The wound edges are approximated and held in place (e.g., with sutures) until healing occurs ○ The wound is easily closed and dead space is eliminated ○ Second intention ○ This type of healing occurs with injuries or wounds that involve tissue loss and require gradual filling in of the dead space with connective tissue. ○ Third intention ○ This type of healing, which involves delayed primary closure, occurs with wounds that are intentionally left open for several days for purposes of irrigation or removal of debris and exudates ○ Once debris has been removed and inflammation resolves, the wound is closed by first intention. III. Psoriasis ○ Chronic, noninfectious skin inflammation involving keratin synthesis that results in the formation of psoriatic patches ○ Possible causes: ○ Stress ○ Trauma ○ Infection ○ Hormonal changes ○ Obesity ○ Autoimmune reactions ○ Changes in climate ○ Genetic predisposition ○ Assessment findings: ○ Pruritus and shedding of silvery white scales on a raised, reddened, round plaque, usually on scalp, knees, elbows, extensor surfaces of arms and legs, and sacral regions ○ Affected nails display yellow discoloration, pitting, and thickening
○ In psoriatic arthritis, joint inflammation occurs ○ Nursing considerations ○ The goal of therapy is to reduce cell proliferation and inflammation. ○ Interventions include prescribed pharmacological therapy, topical treatments and, in some cases, ultraviolet light therapy. ○ Teach the client to wear lightweight cotton clothing over affected areas. ○ Help the client identify ways to reduce stress. IV. Frostbite ○ Damage to tissues and blood vessels is the result of prolonged exposure to cold ○ Fingers, toes, nose, and ears are often affected ○ Assessment findings: ○ Numbness ○ Paresthesia ○ Pallor ○ Severe pain ○ Swelling ○ Erythema ○ Blistering once pt is in warm environment ○ Necrosis and gangrene (severe) ○ Nursing considerations ○ Handle affected tissues gently and elevate them above the level of the heart. ○ Rewarm the affected area in a water bath (98.6° to 104° F) for 15 to 20 minutes to thaw the frozen part. This intervention may be painful. ○ Avoid the use of dry heat, and never rub or massage the affected part. ○ Tetanus prophylaxis is necessary. ○ Antibiotics may be prescribed. ○ Debridement of necrotic tissue may be necessary. V. Pressure Ulcers ○ Staging of Pressure Ulcers
○ Nursing considerations ○ Avoid direct massage of a reddened area of skin, which may damage the capillary beds, resulting in tissue necrosis VI. Burn Injuries ○ Superficial ○ Characterized by mild to severe erythema (pink to red) with no blisters, is painful ○ Skin blanches under pressure
○ Superficial partial-thickness ○ Mottled red base with blistering and edema, with broken epidermis, indicated by a wet, shiny, weeping surface, is present ○ Painful ○ Injured area is sensitive to cold air ○ Deep partial-thickness ○ Injured surface appears dry and red (or white in deeply injured areas) ○ Edema is moderate ○ May convert to full-thickness if tissue damage increases with infection, hypoxia, or ischemia ○ Skin grafting may be necessary
○ Rule of nines is only for adults ○ Burns of the head, neck, and chest are associated with pulmonary complications. ○ Burns of the face are associated with corneal abrasion. ○ Burns of the ear are associated with auricular chondritis. ○ Severe burns of the hands and joints require intensive therapy to prevent disability. ○ The perineal area is prone to autocontamination with urine and feces. ○ Circumferential burns of extremities can produce a tourniquet-like effect, leading to vascular compromise (compartment syndrome). ○ Circumferential thoracic burns may result in inadequate chest-wall expansion and pulmonary insufficiency. ○ Physiological consequences ○ Extensive burns result in generalized edema and a decrease in circulating intravascular blood volume. ○ Fluid losses result in decreased organ perfusion. ○ Heart rate increases, cardiac output decreases, and blood pressure drops. ○ Initially hyponatremia and hyperkalemia occur ○ Hematocrit increases as a result of plasma loss.
○ The body shunts blood from the kidneys, causing oliguria, after which the body begins to reabsorb fluid; diuresis of the excess fluid occurs over the following days to weeks. ○ Blood flow to the gastrointestinal (GI) tract is diminished, leading to intestinal ileus and GI dysfunction. ○ Evaporative fluid losses through the burn wound are greater than normal, and losses continue until wound closure is complete. ○ If the intravascular space is not replenished with intravenous fluids, hypovolemic shock and ultimately death will occur. ○ Phases and Goals of Treatment ○ Resuscitation/Emergent Phase ○ This phase begins at the time of injury and ends with the restoration of capillary permeability, usually 48 to 72 hours after injury. ○ Prehospital and emergency department care includes maintaining a patent airway, administering IV fluids to prevent hypovolemic shock, and preserving vital organ function. ○ Resuscitative Phase ○ This phase begins with initiation of fluids and ends when capillary integrity returns to near-normal levels and large fluid shifts have decreased. ○ The amount of fluid administered is based on the client's weight and extent of injury. ○ Most fluid-replacement formulas are calculated from the time of injury, not from time of arrival at hospital. ○ Shock is prevented through maintenance of adequate circulating blood volume and vital organ perfusion. ○ Acute Phase ○ This phase begins when client is hemodynamically stable, capillary permeability is restored, and diuresis has begun, usually 48 to 72 hours after time of injury. ○ The focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy. ○ Restorative therapy is started, and the phase continues until wound closure is achieved.
○ Be alert for signs of carbon monoxide poisoning, most notably an increased blood level, in the client who has sustained thermal burns. ○ Prepare the client for escharotomy or fasciotomy. ○ Interventions in the Resuscitative Phase ○ Initiate electrocardiographic monitoring. ○ Monitor temperature and assess the client for infection. ○ Initiate protective isolation techniques; ensure that everyone who deals with the client washes his or her hands carefully, use sterile sheets and linens when caring for the client, and use gloves, cap, masks, shoe covers, scrub clothes, and plastic aprons. ○ Monitor weight daily, expecting a weight gain of 15 to 20 lb in the first 72 hours. ○ Monitor gastric output and pH level and be alert to gastric discomfort and bleeding, indicating stress ulcers. ○ Administer antacids, H2-receptor antagonists, and antiulcer medication as prescribed. ○ Auscultate bowel sounds for ileus and monitor the client for abdominal distention and gastrointestinal dysfunction. ○ Monitor the stools for occult blood. ○ Obtain urine specimen for determination of myoglobin and hemoglobin levels. ○ Elevate circumferential burns of extremities on pillows above the level of the heart to reduce dependent edema if no obvious fractures are present. ○ Monitor pulses and capillary refill of affected extremities and assess perfusion of any distal extremity with a circumferential burn. ○ Keep the room temperature warm. ○ Place the client on an air-fluidized bed and use a bed cradle to keep sheets off client's skin. ○ Various fluid resuscitation formulas are available:
○ The amount of fluid administered depends on how much IV fluid is required to maintain a urine output of 30 to 50 mL/hour. ○ Successful fluid resuscitation is evidenced by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. ○ Urine output is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion. ○ Administer pain medication by way of the IV route; avoid intramuscular or subcutaneous administration, because absorption through soft tissue is unreliable in the presence of hypovolemia and large fluid shifts. ○ Avoid administering medication orally because of the possibility of gastrointestinal dysfunction. ○ Medicate the client before painful procedures. ○ Maintain NPO status until bowel sounds are heard, then allow client clear liquids. ○ Nutrition may be provided by way of enteral tube feeding or parenterally. ○ Provide a diet high in protein, carbohydrates, fats, and vitamins. ○ Interventions in the Acute Phase ○ In hydrotherapy, wounds are cleansed by means of immersion, showering, or spraying. ○ The client should be medicated before hydrotherapy. ○ Hydrotherapy is generally not used in a client who is hemodynamically unstable or in one with new skin grafts. ○ If hydrotherapy is not used, wounds are washed and rinsed, with the client in bed, before application of antimicrobial agents. ○ Debridement is the removal of eschar by mechanical, enzymatic, or surgical means, to prevent bacterial proliferation beneath the eschar and to promote wound healing. ○ Wound closure is performed on the fifth to 21st day, depending on the extent of injury, to help prevent infection, loss of fluid, and contractures and promote healing. ○ Autografting (a.k.a. skin grafts), or permanent wound coverage, may be performed to close burn wounds. Grafting involves the surgical removal of a thin layer of the client's own unburned skin, which is then applied to the area of the excised burn wound. ○ Care of graft and donor sites ○ Autografts are immobilized after surgery for 3 to 7 days to allow them to adhere and attach to the wound bed. ○ Elevate and immobilize the graft site.
○ Scarring is controlled with the use of elastic wraps and bandages to apply continuous pressure to healing skin during the period when new skin is vulnerable to shearing. ○ The Pediatric Client ○ Very young children who have been severely burned have a higher mortality rate than do older children and adults with comparable burns. ○ Lower burn temperatures and shorter exposure to heat may cause a more severe burn in a child than in an adult because a child's skin is thinner. ○ A severely burned child is at greater risk than an adult for fluid and heat loss, dehydration, and metabolic acidosis. ○ The higher proportion of body fluid to mass in children increases the risk of cardiovascular problems. ○ Burns involving more than 10% of total body surface area (TBSA) require some form of fluid resuscitation. ○ Infants and children are at increased risk for protein and caloric deficiency because they have less muscle mass and less body fat than do adults. ○ Scarring is more severe in children. ○ An immature immune system presents an increased risk of infection for infants and young children. ○ A delay in growth may occur after a burn. ○ In a pediatric client, the extent of the burn injury is expressed as a percent of TBSA with the use of age-based charts (refer image). ○ Several formulas can be used to calculate the rate of fluid administration; the formula used depends on the health care provider’s preference. VII. Acne Vulgaris ○ Improvement may not be apparent for 4 to 6 weeks ○ Active treatment for control is required until the acne resolves VIII. Bites and Stings ○ Bee and wasp stings produce a toxic reaction because of the venom sac attached to the stinger (usually a wheal-and-flare reaction is seen), but some people are also allergic to the venom and may experience an anaphylactic reaction. ○ If the victim is allergic to the venom of a bee or wasp, a severe allergic response can occur (hives, pruritus, swelling of the lips and tongue) that can progress to life-threatening anaphylaxis; immediate emergency care is required. ○ The bite of a brown recluse spider can cause a skin lesion, a necrotic wound, or systemic effects from the toxin (loxoscelism). ○ The bite of the black widow spider, which appears as a small red papule, injects a neurotoxic venom.
○ A tarantula’s bite results in swelling, redness, numbness, and lymph inflammation, and pain at the bite site. The tarantula may also launch barbed hairs from its body; these hairs can penetrate the skin and eyes of the victim, producing a severe inflammatory reaction. ○ Scorpions inject venom into the victim through a stinging apparatus on the tail. Most stings cause local pain and inflammation. ○ Some snakes are venomous and can cause a serious systemic reaction in the victim. ○ A poison control center should be contacted as soon as possible after a sting or bite to permit selection of the best initial management. ○ Nursing considerations ○ Brown recluse spider bites ○ Apply ice immediately and intermittently for as long as 4 days after the bite to inhibit the action of the neurotoxin. ○ Topical antiseptics and antibiotics may be prescribed if the site becomes infected. ○ Black widow spider bites ○ Ice is applied immediately to inhibit the action of the neurotoxin. ○ Systemic toxicity can occur; victim may require supportive therapy in the hospital. ○ Tarantula bites and hair exposure ○ Tarantula hairs must be removed as soon as possible from the client’s body; use sticky tape to pull hairs from the skin, then thoroughly irrigate the skin (saline irrigation is performed in cases involving eye exposure). ○ The involved extremity is elevated and immobilized to reduce the pain and swelling. ○ Antihistamines and topical or systemic corticosteroids may be prescribed; tetanus prophylaxis is necessary. ○ Scorpion stings ○ Mild systemic reactions are treated with analgesics, wound care, and supportive treatment. ○ The bark scorpion, with its neurotoxic venom, can inflict a severe and fatal systemic response; the victim is taken to the emergency department immediately, where antivenom can be administered. ○ Bee and wasp stings
IX. Inflammatory and Infectious Disorders ○ Eczema ○ Superficial inflammatory process, mainly involving epidermis, manifests as redness and itching accompanied by minute papules and vesicles ○ Nursing considerations ○ Avoid exposing the skin to irritants and conditions that might exacerbate itching (e.g., soaps, detergents, fabric softeners, baby wipes, powder, wool clothes and blankets, furry stuffed animals). ○ Improve skin hydration; apply lotion after bathing. ○ Prevent or minimize scratching; keep the affected child's nails short and clean and place gloves or cotton socks over the hands if necessary. ○ Instruct the client or parent to put clothes through a second complete wash cycle without detergent, which will minimize the amount of residue on fabric. ○ Monitor the client for skin infection. ○ Antihistamines and topical corticosteroids may be prescribed. ○ Poison Ivy, Oak, and Sumac ○ Dermatitis, signaled by papulovesicular lesions and severe itching, develops as a result of contact with urushiol from the plant ○ Nursing considerations ○ Cleanse the skin of plant oils immediately. ○ Apply cool dressings to relieve itching. ○ Apply lotion or topical ointments. ○ Oral corticosteroids may be prescribed for severe reactions.
○ Candida albicans Infection ○ This superficial fungal infection of the skin and mucous membranes is also known as a yeast infection or thrush (when it involves the mouth). ○ C. albicans infection is most often seen in clients who are immunosuppressed, clients undergoing chemotherapy or long-term antibiotic therapy, the obese, and individuals with diabetes mellitus. ○ Affected skin is red, itchy, and burning; thrush manifests as red and whitish patches. ○ Nursing considerations ○ Keep skin, especially skinfold areas, clean and dry. ○ Provide or instruct client to perform mouth care frequently, avoiding irritating products. ○ Provide tepid food and fluids that are nonirritating to the mucous membranes. ○ Antifungal medication will likely be prescribed. ○ Herpes Zoster (Shingles) ○ Acute viral infection of the dorsal nerve root ganglion is caused by the varicella zoster virus. ○ Shingles may be a result of reactivation of the varicella zoster virus or initial exposure to the virus; it may also occur during any immunocompromised state. ○ Unilaterally clustered skin vesicles appear along the paths of peripheral sensory nerves on the trunk, thorax, or face ○ Nursing considerations ○ Take contact precautions; exudate from lesions contains the virus. ○ Keep blisters intact. ○ Begin antiviral agents as soon as possible after diagnosis. ○ Administer antiviral agents and other medications as prescribed. ○ Prevent the client from scratching or rubbing affected areas. ○ Monitor the client for bacterial infection of scratched areas. ○ Instruct the client to wear loose, lightweight cotton clothing and to avoid wool and synthetic garments.
