Nursing Care of Patients with Integumentary Diseases

Superficial (1st degree) burn

*Damage ONLY to epidermis.* Epidermis is pink/red, slightly edematous, dry, painful, tender, & hypersensitive; no skin loss or blister (sun burn). The skin blanches to touch. Heals in 3-7

Deep partial-thickness (2nd & 3rd degree) burn

*Damage to all epidermis & deeper layers of the dermis.* White, dry, less sensitivity to pain, blanches with pressure. pain, blistered and mottled red skin, and edema Heals in 2-6 week

Superficial partial-thickness (1st & 2nd degree) burn

*Damage to all epidermis & part of the dermis.* Weeping blister, more swollen, very painful, sensitive to air. Heals in 10-21 days (2-3 weeks).

Full thickness burns (3rd & 4th degree) burn

*Damage to the entire dermis & sometimes into the subcutaneous fat layer.* White or blackened. Extends into muscles, nerve, vessels, bone. The area maybe insensitive to touch, to pain & cold with Little or NO Pain due to nerve destruction. Skin cannot heal on its own.

Stage 4 Pressure Injury

*Full-thickness skin loss with exposed or palpable muscle, tendon, bone, or supportive tissue.* Eschar or slough may be present in some parts of the wound. •Undermining & tunneling common with sinus tracts possible slough & eschar often present

Stage 3 Pressure Injury

*Full-thickness skin loss* •Subcutaneous tissue & underlying fascia may be damaged or necrotic •Bone, tendon, muscle NOT exposed •May have undermining and tunneling

Stage 1 Pressure Injury

*Skin intact & red* •Intact skin with non-blanchable redness of a localized area.

Stage 2 Pressure Injury

*Skin not intact* •Partial-thickness skin loss of dermis •Injury (Ulcer) is superficial, wound may appear as an abrasion, blister, or shallow crater, a shallow open ulcer (injury) with a red-pink wound bed, without slough.

Cellulitis treatment

*Systemic Abx; immobilize, Elevate affected extremity, ↓ swelling, dressing change; Apply moist heat, affected area should be left open to air, not wrapped by ACE bandage.* •Warm compresses may ¯ the discomfort, erythema, & edema associated with cellulitis. •Provide supportive care as prescribed to manage associated symptoms such as fever or chills. •After tissue & blood are obtained for culture, antibiotics are initiated. • *If pt c/o urticaria shortly after IV Abx → First, stop IV infusion, then assess V/S; contact provider & then document the reaction to drug, pt's response & interventions that were done, & initiate an adverse effect report.* •*To evaluate effectiveness of Tx: observe for S/S of inflammation*

Total Parenteral Nutrition (TPN)

- (TPN) supplies all daily nutritional requirements. - Indications: pts who do not have a functioning GI tract or who require complete bowel rest; Ulcerative Colitis, Crohn's disease exacerbation. •Must be given via Central line: Hypertonic, can cause thrombosis. •Must use IV pump: Prepare infusion pump before hanging TPN solution. •Use of infusion pump is important to ensure that solution does not infuse too quickly or delayed since TPN has a high glucose content. *IMPORTANT: When TPN IV bag is empty, give pt D10W (Hypertonic IV Dextrose solution) to prevent hypoglycemia*

Fluid Resuscitation

- *Burns require a massive amount of fluid resuscitation. LR is the fluid of choice.* - *Hypotension & low CVP (normal 2-8 mm Hg) indicate the need for additional IV fluids.* - *There is NO evidence to support the O2 in case of hypovolemia, unless pt is hypoxic & in respiratory distress.* - Fluid resuscitation is determined by urine output; hourly urine output should be at least 30 mL/hour. To determine whether pt receives adequate fluid infusion, monitor U/O. - U/O of < 30 mL/hr is indicative of insufficient fluid resuscitation, which places the pt at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. - Successful or adequate fluid resuscitation is signaled by stable V/S, adequate U/O, palpable peripheral pulses (2+ or better), & clear sensorium (Pt is oriented to client, place, and time), Blood pH within normal range 7.35 - 7.45. Yet, the most reliable indicator of fluid resuscitation, especially in a pt with burns, is urine output. For an adult, hourly urine volume should be 30 to 50 mL.

Psoriasis Pharmacologic Treatment

- *Topical agents*: Emollients, Salicylic Acid, *Corticosteroids for inflammation*, vitamin analogues - *Psychosocial Support: Shake pt's hand during to address psychosocial needs for acceptance.* •Touch communicates acceptance of pt with a skin problem such as psoriasis

Psoriasis patient education

- *Topical application of steroids*: corticosteroids (e.g. Triamcinolone) *↓ inflammation*, coal tar shampoo/soaps, topical vitamin D •Steroids applied locally, lesions usually covered with plastic wrap at night to reverse inflammatory process. •*Covering affected area with an occlusive dressing enhances steroid's effectiveness.* This intervention should be limited to 12 hours per day to ↓ systemic & local side effects. •*Penetration of topical steroid can be enhanced by applying warm, moist heat & an occlusive outer wrap.* •The wrap may consist of a plastic film, glove, bootie, or similar item. •*The medication is applied but not rubbed into the skin.* •Emollients should be cold & fragrance free •Avoid skin injury (this can cause plaque/scale formation), avoid meds that worsen psoriasis (aspirin, beta blockers)

Varicella zoster

- *a virus that precedes herpes zoster & can be presented as shingles. It may be manifested as cold sores on the mouth.* •*The virus infects the dorsal root ganglia of nerves & can cause intense itching and outbreaks of multiple lesions in segmental distribution patterns of skin dermatomes that are innervated by infected nerves.* •Reactivated varicella virus, dormant in ganglion cells; Prodromal stage

Tertiary Intention

- Delayed closure; high risk for infection with resulting scar. •Combination of both primary & secondary intention. E.g. traumatic wounds. •Wound is infected & left open to be cleaned, debrided, & heal, is allowed to granulate, then approximated/sutured closed after controlling infection.

Care of Burn Patient in EMERGENT Phase

- During the emergent phase, because of fluid volume deficits 2ndary to burn injury, monitor V/S hourly until pt is hemodynamically stable. - Monitor mental status every hour for the first 48 hours. - Weigh pt & record wt daily or twice daily. - Record I/O hourly.

Eczema (Atopic Dermatitis)

- Eczema is a general term for many types of skin inflammation (dermatitis). A chronic, pruritic skin dz with wide range of severity. - Most common type of eczema: atopic dermatitis (Scaling, itching, redness & excoriation). - Eczema is not contagious.

Primary Intention

- Edges brought together with skin lined up in approximated position - EDGES ARE APPROXIMATED usually brought together with suture or steri strips

Contact Dermatitis, AKA Diaper Rash

- Example of Irritant contact diaper dermatitis. - Inflammatory reaction in the region covered by a diaper including chemical allergies, sweat, yeast, or friction irritation. - Common areas: perineum, buttocks, lower abdomen, and inner thighs. Clinical Presentation: Red to bright red (erythematous), sometimes shiny, wet-looking patches and lesions on the skin.

Secondary Intention

- Granulation & contraction; deeper tissue injury or wound. •When edges cannot be approximated OR when we should not approximate wound edges because of infection risk. We leave the wound open & may pack it to help heal by granulation from the bottom up.

Herpes Zoster (Shingles)

- Infection caused by varicella-zoster virus.; can cause chickenpox & then shingles in later years. •Shingles is caused by herpes zoster. Herpes zoster is the same virus as the varicella-zoster, which causes chickenpox. This virus is a retrovirus that never dies; it becomes dormant & lives in the body along nerve pathways. •During times of stress, it can erupt as herpes zoster (shingles). Herpes zoster is caused by a reactivation of the varicella-zoster virus. •The pain usually occurs prior to the eruption of the vesicles. •It was thought for years that there were two separate viruses. Research has proven that the varicella virus & zoster are the same; therefore, nurses who have not had chickenpox should not care for this pt.

Psoriasis non-pharm tx

- No cure, symptomatic tx; Avoid alcohol, ↓ stress, ↓ sun exposure •Ultraviolet Light Tx: *UVA Radiation, a type of ultraviolet radiation; alternate to UVB if unsuccessful; penetrates deeper into skin.* (possibly biologic tx, but NEVER 1st line). *PUVA (Psoralen & Ultraviolet A light) or photochemotherapy is a type of ultraviolet radiation tx (phototherapy) used for severe skin dz.* •*Erythema, edema & tenderness indicate overexposure to ultraviolet light; so stop Tx for a few days.* •UV Tx limited to 2 or 3 times a week & not given on consecutive days. •Safety precautions required during UV light Tx: Protective dark eye goggles required to prevent exposure of the eyes to the UV light. •Use moisturizers with ALL choices to treat psoriasis.

Psoriasis

- Psoriasis Vulgaris is the most common type: common, autoimmune, non-infectious chronic dermatitis involving excessively rapid turnover of cells •Thick red raised papules or elevated plaques, covered with silvery-white patches / scales •Chronic, periods of exacerbation & remission; red & scaly plaques; emotionally & physically debilitating •Onset generally occurs before age 40, with S/S varying in intensity from mild to severe.

Melanoma Tx

- Tx determined by site of original tumor; Stage of the cancer; Pt's age & general health •Tx includes surgical incision & adjuvant tx: Melanoma that has spread to the lymph nodes or nearby sites usually requires additional (adjuvant) tx such as chemotherapy, biologic therapy (e.g., α-interferon, interleukin-2), and/or radiation tx. •*Avoid excessive exposure to sunlight.*

Impetigo

- superficial infection of epidermis •A highly contagious bacterial skin infection, Large, flaccid bullae with honey-colored crusts around the mouth & nose are characteristics of impetigo. •Lesions are extremely contagious & should not be touched, except when wearing gloves. •Wearing gloves & meticulous hygiene is imp. when caring for pt

Three Phases of Burn Management

1. Emergent (Resuscitative): Immediate problems; Maintain airway, fluids, analgesia, temp., wound - The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the pt is considered physiologically stable. 2. Acute (Wound healing): Wound care should be delayed until patent airway, adequate circulation, & adequate fluid replacement have been established - The acute phase lasts until all full-thickness burns are covered with skin. 3. Rehabilitative (Restorative): Formal rehab begins as soon as functional assessments can be performed - The rehabilitation period lasts approximately 5 years for an adult & includes reintegration into society.

1. Emergent Phase (from onset of hypovolemic shock & edema formation) Hypovolemic stage

A. Hypovolemic stage - begins at onset of burn; lasts for 1st 48 - 72 hours •Rapid fluid shifts - from vascular into the interstitial spaces •Capillary permeability with burns increases with vasodilation •Fluid loss deep in wounds •Initially Na & H2O; Protein loss - hypoproteinemia •Hemoconcentration - Hct increases; Low blood volume, oliguria •Low Na; High K; - damaged cells release K, Metabolic acidosis.

Wound Contamination/Infection

An exposed wound is always contaminated but not always infected! •Contamination - Presence of organisms without infection •Infection - *When there is purulent discharge from a wound, priority is to send sample for culture & sensitivity.*

1. Emergent Phase (from onset of hypovolemic shock & edema formation) Diuretic Stage

B. Diuretic Stage - begins 48 - 72 hours after burn injury •Capillary membrane integrity returns •Edema fluid shifts back into vessels - blood volume increases •Increase renal blood flow - result in diuresis (unless renal damage) •Hemodilution - low Hct, decreased potassium (excreted in urine) •Fluid overload can occur due to increased intravascular volume •Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism •Fluid shifts resolving: pt is still acutely ill (malnutrition; anemia) The emergent phase ends when fluid mobilization & diuresis begins

Cause & Risk Factors of Melanoma

Cause: unknown: Environmental factors; Genetic factors *Risk factors: Red or blonde hair; Light-colored eyes; Light colored (Fair) skin; Excessive or Chronic sun exposure (e.g. construction workers); Family Hx; Age > 60 yrs, occupation exposure to arsenic, which is commonly used in pest control* •*Pts with very little melanin in skin (fair-skinned without using tan) have ↑ risk of skin CA due to UV damage to underlying membranes*

Herpes Zoster Assessment

Common S/S: An area of skin that burns, itches, tingles or feels very sensitive. •The primary lesion of herpes zoster is a vesicle. Classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, lesions do not cross the body's midline. •A rash that begins as red spots & quickly turns into groups of clear, painful blisters often on one side of the body. •Painful vesicular eruption in dermatome •Unilateral on the trunk, face, & lumbosacral areas

Cardiovascular Assessment

Decreased Cardiac Output Interventions: •Monitor vital signs. •Monitor cardiac status especially in cases of electrical burn injuries. •*Pt who receives circumferential burns to extremities is at risk for altered peripheral circulation.* •*Priority assessment would be to assess for peripheral pulses to ensure adequate circulation is present.* •Increase blood fluid volume •Support compensatory mechanisms •Prevent complications •Intravenous fluid therapy •Plasma exchange therapy •Surgical management: escharotomy

Herpes Zoster Diagnosis

Diagnosis: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides a definitive diagnosis.

How to confirm diagnosis of skin cancer?

Diagnostic Tests:Inspection & hx; Biopsy; Stains & cultures •The only way to confirm if a skin growth is cancerous is to biopsy it [Punch biopsy]; consent required. •A skin biopsy is not painless. Most common pain source during skin biopsy is the initial local anesthetic, which can cause burning/stinging sensation. Sutures usually removed 7 to 10 days after biopsy.

Eczema Triggers

Eczema is likely related to conditions that adversely affect skin's barrier function (including nutrient deficiencies, bacterial infection, and dry, irritated skin). •Foods: nuts & dairy; environmental factors such as smoke & pollen can trigger S/S. •Dry skin: When skin gets too dry, it can easily become brittle, scaly, rough, or tight, which can lead to an eczema flare up. •Allergens: seasonal pollen, dust mites, pet dander from cats & dogs, mold. •Irritants: substances that can cause skin to burn & itch, or become dry & red — hand & dish soap, laundry detergent, shampoo, bubble bath & body wash, or surface cleaners

Onychomycosis (nail)

Fungal infection related to fingernails or toenails.

Burn Pathophysiology

In extensive burn injuries (> 25% of TBSA), generalized edema occurs in both burned & unburned areas as a result of ↑ capillary permeability & hypoproteinemia → ↓ circulating intravascular blood volume.

Contact Dermatitis treatment

Non-Pharm Tx: frequency of diaper changes, gentle rubbing or patting with a bland, soft cloth or wipe is appropriate. •Skin Care: Petroleum/ white petroleum ointments are excellent skin protectants. •Zinc Oxide: The hydrophobic nature of zinc oxide is beneficial in forming a protective barrier for the compromised skin, the down fall is the necessity of soap to remove it. •Calamine lotion: a mixture of zinc & ferrous oxide. It has absorptive, antiseptic, & antipruritic properties

Non-melanoma vs melanoma

Non-melanoma: - benign - symmetrical - even borders - one color - smaller than 1/4 inch - ordinary mole Melanoma - malignant - asymmetrical - uneven borders - two or more colors - larger than 1/4 inch - changing in size, shape, color, or another trait

Respiratory Assessment

Nursing Interventions: • lung compliance; Improve PaO2 •Give positive end-expiratory pressure (PEEP); Use intermittent mandatory volume. •Document & report any S/S of respiratory distress. •Use neuromuscular blocking agents. •Monitor ABGs.

Electrical injuries

Remove patient from contact with source.

furunculosis & carbunculosis risk factors and treatment

Risk factors of furunculosis & carbunculosis: •Poor hygiene, Steroid, Weak immune system, DM, CA •Skin conditions: Dermatitis, scabies, eczema Treatment: I & D; Systemic antibiotics

Malignant Melanoma Tumor Staging •The 5-year survival rate depends on sentinel node biopsy results, which indicate if metastasis has occurred.

Stages O-IV based on: Tumor size; Nodal involvement; Metastasis; T-N-M. Stage O: melanoma cells are only on the outer layer of the skin - If diagnosed at stage 0, melanoma is nearly 100% curable by excision. Stage I: cancerous tumor has formed Stage II: tumor is classified by specific stage depending on thickness and whether skin is ulcerated (broken) Stage III: melanoma has spread to nearby lymph vessels, lymph nodes, and/or nearby skin Stage IV: melanoma has spread to other organs in the body or areas far from the orig site of the tumor - If metastasis to other organs is found (stage IV), tx becomes palliative

Impetigo Tx

Systemic antibiotics are Tx of choice for impetigo & should be continued as prescribed. •Administer an antibiotic ointment (e.g. Polysporin) "OTC" four times a day. •Crusts should be removed before the ointment is applied. Soak a soft, clean cloth in a mixture of one-half cup of white vinegar & a quart of lukewarm water. •Press a cloth on the crusts for 10 to 15 minutes 3 or 4 times daily. Then gently wipe off the crusts & apply Abx ointment. •Remove crusts with warm saline followed by soap & water, followed by topical antibiotic cream. •Instruct parents to keep child at home until lesions crust over. •Use separate towels and linen for pt. Pt's towels, pillowcases, & sheets should be changed after the first day of tx. The clothing should be changed & laundered daily for the first 2 days. •Thorough hand washing, separate washing of pt's dishes bc infection is contagious so long as skin lesions are present.

Parkland (Baxter) Formula:

Total fluid replacement in 24 hrs: 4ml x TBSA (%) x body weight (kgs) - Give 50% in 1st 8 hours (from time of burn, not time admitted to hospital) AND give the other 50% in next 16 hours •E.g. for a 70 kg pt with 60% burn, Total fluid for 1st 24 hrs = 4x70x60 = 16800 mL of LR •If pt arrives 2 hrs s/p burn, 50% of the total fluid is given over 6 hrs (8-2 = 6). •If pt arrives 9 hours s/p burn, the total amount of fluid is given over 15 hours (24-9 = 15).

Pruritis Tx and Meds

Tx: eliminate the cause & eliminate the itch! (use lotions, humidifiers, *keep nails trimmed/ short due to itching*, keep temperatures cool). *Oatmeal bath for reducing itching and pruritis.* •Meds: as necessary (topical antihistamines or corticosteroids for insect bites or hives)

Deep full thickness (4th degree) burn

involve bone & tendons •Destruction of entire epidermis, dermis, subcutaneous tissue, connective tissue, muscle, and *bone*. •Skin does NOT regrow. *Graft is needed. Monitor CVP, electrolytes, edema.*

Wound Healing

primary intention secondary intention tertiary intention

Psoriasis risk factors

stress, trauma, infection, hormonal changes (menopause), obesity, climate changes; genetic predisposition, Family Hx.

Rashes

temporary eruptions of the skin (heat rash, drug induced reactions)

Resuscitation/Emergent Phase

• begins at the time of injury & ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. •During the resuscitation/emergent phase (in first 24 hours after injury), the hematocrit level ↑ to above normal because of hemoconcentration from large fluid shifts (from loss of intravascular fluid). •Hematocrit levels of 50% to 60% are expected during first 24 hours after injury, with return to normal by 36 hours after injury. •Normal hematocrit level ranges from 42% to 52%, depending on gender. •Initially, blood is shunted away from the kidneys and renal perfusion & GFR ↓ resulting in low urine output. •The burn pt is prone to hypovolemia & the body attempts to compensate by ↑ HR & ↓ BP. Pulse rates are typically higher than normal, & BP is ↓ as a result of the large fluid shifts

Eczema Treatment cont.

•*Antihistamines: may be used to treat itch associated with atopic dermatitis (AD)* - *Commonly used to treat allergic reactions*, including hay fever, hives, & other skin reactions. Over-the-counter oral antihistamines like Benadryl, Zyrtec might help with allergic dermatitis. If pt frequently experiencing contact dermatitis due to minor allergies, pt can take a prescription allergy medication to prevent future outbreaks. •Skin care must be meticulous. Minimal soap and tepid water should be used when showering or bathing. Lotions that do not irritate should be used to keep skin hydrated.

Herpes Zoster Nursing Implications

•*Assess & manage pt pain using pain scale & OPQRSTU* •*Maintain skin integrity & pt's functional ability.* •Cool rash with ice packs, cool wet cloths, or cool baths. •Gently apply calamine lotion to the rash and blisters. •Never pick at, scratch or pop blisters; the fluid within the blisters can be contagious & blisters help the skin heal. •*Cover rash with loose, non-stick (non-inherit), sterile bandages.* •Wear loose, cotton clothing around body parts that hurt. •*Stay away from children & pregnant women who have not had chickenpox* •*Nurses who have not had chickenpox or did not receive the varicella-zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster.*

Assess lesions for ABCDE features associated with Malignant Skin Neoplasms

•*Asymmetry* •*Border irregularity* •*Color change (black)* •*Diameter > 6 mm* •*Evolving in appearance*

Eczema Treatment - Focuses on healing damaged skin & alleviating s/s

•*Barrier/Moisturizing creams*: Local application of Petroleum jelly, Aquaphor, Aqua-care, Eucerin. - *Evaluation of effectiveness of aqua-care & other moisturizers: Hydration of dry skin (Moist skin = less dryness) → aqua-care cream is working* - *Aqua-care: an emollient & cream with 10% urea that penetrates skin surface to facilitate hydration & moisturize dry skin.* •*Topical corticosteroids: to treat contact dermatitis, which comes from an allergic response to irritants.* - *Irritant should be eliminated & topical anti-inflammatory creams should be administered.* - *Absorption of corticosteroid cream for eczema is higher on the scalp, axilla, face, neck, perineum (anus area) and genitalia.*

Treatment of Tinea Pedis

•*Feet should be well ventilated/breathable, dry feet well after bathing* •*Use clean socks & shoes; change socks; do not share towels, bathe feet daily & dry; talcum powder or antifungal powder* •Soak feet with vinegar & water solution to help remove the crust, scales, & debris to ¯ the inflammation in a pt diagnosed with athlete's foot. •Vinegar is mildly acidic, which helps remove crusts.

Care of Burn Patient in EMERGENT Phase cont.

•*Maintain patent airway - watch for laryngeal edema*, •100% FiO2 mask; intubation for inhalation most often required •*Maintain circulation *- fluid resuscitation - crystalloids and colloids. Crystalloids - may be isotonic or hypertonic. •*Two large-bore IV lines for >15% TBSA* •Type of fluid replacement based on size/depth of burn, age, and individual considerations •Parkland (Baxter) formula for fluid replacement •*Isotonic - most commonly LR (if no Renal Failure)* •LR solution is an isotonic solution; contains electrolytes; will maintain fluid volume in circulation. •Ringer's Lactate is fluid of choice as interstitial fluid shifting depletes vascular volume.

Melanoma patient education

•*Malignant melanoma can be fatal if not detected early.* •*Post resection of malignant melanoma & with any skin assessment, teach pt to assess for & report any MOLE asymmetry, border notching, color changes (black), or diameter > 6 mm as these may indicate melanoma.*

Pressure Ulcer prevention

•*Most important is Frequent Positioning at least Q 2 hours.* •Pressure-Relieving Techniques: Pressure-relief products/devices •*When changing position of pt offer fluid intake Q 2 hours to prevent complications of immobilization.* •Use a pillow to keep heels off the bed when supine. •Lift pt with a "lift" pad rather than pulling pt against sheets to prevent skin damage from friction shearing •Avoid massaging pressure points as this tissue damage & risk of skin breakdown. •Appropriate perineal care is essential to keep waste products from excoriating the skin

Wound Management: Nonsurgical

•*Normal saline: preferred method for cleansing wounds (including Pressure Ulcers), since it is a physiological solution & will not damage any new growth tissue.* •Give parenteral analgesic 30 min. before changing pressure ulcer wounds •Wound VAC; Hyperbaric Oxygen Therapy (HBOT) - For stage 1 & 2 pressure ulcers, wound care is usually conservative (i.e., non-operative) - For stage 3 & 4 lesions, surgical intervention (e.g., flap reconstruction) may be required. - Approximately 70-90% of pressure ulcers are superficial and heal by second intention - Wound bed preparation for debridement is essential in chronic wound management. Clean the wound then apply collagenase (santyl) ointment for its debriding effect

Burn Management Nursing Interventions

•*Oral diet therapy: high- calorie, high-protein diet along with vitamins (Vitamin D).* - Encourage pt's family to bring favorite foods. - Pt needs sufficient nutrients for wound healing & 'd metabolic requirements; homemade nutritious foods are usually better than hospital food. This also allows family to feel part of pt's recovery. •Enteral tube feedings for pts who cannot swallow •Parenteral nutrition given intravenously

What can people with eczema also develop?

•*People who have eczema may also develop allergic disorder (hay fever, asthma).* •*Atopic dermatitis is a persistent IgE- mediated rash known to be associated with asthma & hay fever.* •*Asthma & atopic dermatitis are atopic diseases with the same pathogenic base with regard to allergic reaction and type of oversensitivity leading to allergic inflammation. Therefore, atopic dermatitis may be associated with asthma or hay fever.* •IgE is a protein responsible for allergic reactions.

Electrical Burns cont

•*Pts at risk for arrhythmias (V-Fib) or cardiac arrest*, severe metabolic acidosis, myoglobinuria. •Electrical sparks may ignite pt's clothing, causing a combination of thermal flash injury. •Severity of injury can be difficult to assess; most damage occurs beneath skin "Iceberg effect" •Electrical current may cause muscle spasms strong enough to fracture bones •Myoglobin and hemoglobin from damaged RBCs travel to kidneys --> Acute tubular necrosis (ATN); Eventual acute kidney injury (AKI)

Goals of management of Patient in Emergent Phase

•*Secure airway* •*Support circulation - Fluid replacement* •Prevent infection; Maintain body temperature •Provide emotional support •Prevent VTE: Enoxaparin (Lovenox to prevent DVT)

Escharotomy Intrvention

•*To prevent infection by auto-contamination, change gloves between wound care on different parts of pt's body.* •Dress each burn wound separately using aseptic technique. •New sterile dressing for each burn wound separately.

Varicella vaccine

•*Varicella vaccine is indicated for persons > 60 years who had chickenpox in the past.* •*The vaccine is effective in decreasing the sores of herpes zoster.* •*After Varicella vaccine → Apply cool pack to increase comfort*

Eczema s/s and cause

•*primary S/S is pruritis "the itch that rashes"*; burning, *erythema* w/ scale & excoriations, *small oozing vesicles*, papules, crusting & thickening of skin; *redness, swelling, blistering, itching, & weeping.* •*Most eczema types cause dry, itchy skin & rashes on the face, inside the elbows & behind the knees, & on the hands and feet.* •Cause: unknown; likely both genetic & environmental factors.

Priuritis Care

•A cool environment ↓ itching. Keep the skin lubricated & cool •Soaps cause itching to ↑. The pt should avoid soap when experiencing pruritus. •Tepid, cool water is better for pt who is itching. Use tepid water for bathing. After bathing, pat skin dry rather than rubbing it •Mild lotion can help the skin stay hydrated. •Apply a lubricant immediately after the bath, while the skin is still damp, to help ↑ hydration of the stratum corneum. •The pt should dry off completely after bathing & blot gently rather than rub vigorously.

For wound covering by autograft, skin from a remote unburned body area is transplanted to cover the burn wound.

•A full-thickness burn will require terminal coverage with an autograft - the pt's own skin. •After surgery, graft sites are immobilized with bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings should not be disturbed. •Elevation & complete rest of grafted area is required for blood vessels to connect the graft with the wound bed. •Any activity that might cause movement of the dressing against the body & separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.

Pharmological Treatment of Tinea Pedis

•Antifungal meds (e.g. azoles [Miconazole, Clotrimazole]) •*If pt taking Abx to treat Tinea Pedis, ask pt to stop Abx & dry athletic feet because Antibiotics do not work for fungal infection* • *antifungal, e.g. Terbinafine (Lamisil).* - *Side effects include Hepatotoxicity* - *Contraindication: liver failure* •Tolnaftate (Tinactil): Antifungal powder or cream to treat Tinea Pedis (Hint: remember TTT) Tinea Pedis Tx = *Tolnaftate (Tinactil) & Terbinafine*

Herpes Zoster Tx - *Goals of Tx should include improving pt's pain, functional ability, & skin integrity*

•Antivirals [Acyclovir "Zovirax", valacyclovir (Valtrex)], Anticonvulsant (*Gaba*pentin/Neurontin; Pr*gaba*lin),topical lidocaine, PO steroids, pain meds (e.g. Morphine) though Shingles does NOT respond to traditional analgesics. •Antiviral meds will suppress S/S but do not cure the disease. They suppress the virus replication, but herpes is a retrovirus, which means it never dies as long as the host body is alive. •When used within 72 hrs of rash appearing, pain meds, antiviral, & anticonvulsants make S/S milder & shorter •Dressings, Immunize adults > 60 yrs with Zostavax, 1 dose

Skin Cancer Prevention

•Avoidance of environmental hazards; Adequate hygiene & nutrition; Skin self-examination •*Environmental Hazards: Sun exposure; Irritants & allergens; Radiation; Sleep; Exercise; Hygiene; Nutrition* •Sunscreen products range in numerical value from 4 to 50; the higher the #, the greater the UV protection. •The lower the SPF # of sunscreen, the less protection. A sunscreen of SPF 15 is a minimum. •Teach pt to avoid sun exposure between hours of brightest sunlight: 10 a.m. and 4 p.m. (late afternoon is ok.) •Sunscreen, a hat, opaque clothing, & sunglasses should be worn for outdoor activities. •Teach pt to examine body/skin monthly for appearance of any cancerous or any precancerous lesions. •Reapply sunscreen every 2-3 hours & after swimming or sweating; otherwise, duration of protection is ¯. •Self-exam: The American Cancer Society recommends a monthly thorough skin check using mirrors to identify any suspicious skin lesion for early detection. •If any lesion is noticed, measure the lesion & note the color; use the ABCD rule.

Chemical injuries

•Brush solid particles off skin; use water lavage •In a chemical burn injury the burning process continues as long as the chemical is in contact with the skin. •All clothing, including gloves, shoes, & undergarments, is removed immediately, & water lavage is instituted before & during transport to the emergency department. •Powdered chemicals are first brushed off the pt before lavage is performed. •Pt who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement & Tx of possible shock, & is prepared for esophagoscopy & barium swallow to determine the extent of damage. •NG tube may be inserted, but gastric lavage & emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

Renal/Urinary Assessment

•Changes are related to cellular debris & decreased renal blood flow. •Myoglobin is released from damaged muscle & circulates to kidney. •Assess renal function, BUN, serum creatinine, & serum sodium levels. •Examine urine for color, odor, and presence of particles or foam.

Gastrointestinal Assessment

•Changes in GI function expected •↓'ed blood flow & sympathetic stimulation during early phase cause reduced GI motility, paralytic ileus •Assess for gastrointestinal bleeding. •Assess for paralytic ileus/obstruction •*Curling's (Stress) ulcer* - Proton pump inhibitors (PPIs) such as Protonix ↓ gastric secretion and are prescribed for pts to prevent Curling's stress ulcer. - Gastric pH should be maintained at 7 or > with the use of prescribed antacids, histamine 2 (H2) receptor-blocking agents or PPI. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of gastric lining and ulcer development. - Bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.

Pressure Injury (formerly called Pressure Ulcer)

•Compression of skin & underlying soft tissue between bony prominence & external surface for extended period •Mechanical forces create injuries (ulcers): Pressure; Friction; Shear •When a pt is lying supine, the heels, sacrum, & back of head all are at risk, as are the elbows & scapulae. •The greater trochanter& ankles are at greater risk of skin breakdown from excessive pressure when the pt is in the side-lying position.

Full-Thickness Wounds

•Damage extends into lower layers of dermis, underlying S/C tissue •Must be filled with granulation tissue to heal •Contraction develops in healing process •When suspect wound infection (e.g. high fever, leukocytosis with shift to the left, purulent foul smell drainage), you should 1st take wound culture

Partial-Thickness Wounds

•Damage to epidermis, upper layers of dermis •Heal by re-epithelialization within 5 to 7 days •Skin injury immediately followed by local inflammation

Integumentary Assessment

•Determine size and depth of injury. •Determine % of total body surface area affected. •Use "rule of nines," using multiples of 9% of total body surface area (TBSA). •Criteria for depth of injury are based on appearance & associated characteristics

Electrical Burns

•Electrical burns have an entry site and exit site. •*Current that passes through vital organs will produce more life-threatening sequelae* than current that passes through other tissue. •*Place pt on cardiac monitor; monitor for arrhythmias* •*The electrical current in the body bounces off bone and goes through muscle. The heart is a muscle; therefore, the priority intervention in electrical burns is for the nurse to apply cardiac monitors to assess for lethal dysrhythmias that may occur.*

Structure of Skin

•Epidermis •Dermis •Subcutaneous tissue •Skin appendages - Skin can ONLY regenerate if dermis is present - If S/C layer is destroyed- bones & muscles may be exposed

Burn Management

•First, remove person from source of burn & stop burning process •Rescuer must be protected from becoming part of incident •At the scene of fire, the pt should be placed or maintained in supine position; otherwise, flames may spread to other parts of the body, causing more extensive injury. •Flame burns may be extinguished by rolling the pt on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water.

Herpes Zoster Assessment cont.

•Flu-like Symptoms: fever or headache may occur with the rash Pain: Sometimes, pain is severe. *Patients suffer from Chronic Pain* •Post-herpetic neuralgia— *Neuropathic Pain (where the rash is) → Complete pain Assessment*. •*Many older adults experience post herpetic neuralgia pain for months following an episode of shingles.* •*Nurse should complete a thorough pain assessment to evaluate effectiveness of pt's current pain management.*

Inhalation Burn Injury

•For inhalation burn injury, assess RR every hour, monitor SPO2 every hour, assist pt in coughing & deep breathing every hour. •Elevate the head of the bed to facilitate lung expansion.

Chemical Burns

•If a large tank of chemicals is spilled onto a pt, the occupational health nurse should FIRST have the pt stand under a shower WHILE removing all clothes. •The skin should be immediately soaked w/constant stream of water to remove the poison from the client's skin and to prevent further damage. •Time should not be lost by removing clothes first and then proceeding to rinsing with water. •If a dry powder form of white phosphorus or lye spilled onto the client, it is brushed off and then the client is placed under the shower. •If the client becomes dyspneic, administer oxygen by nasal cannula.

Burn complications

•Infection, likely caused by gram negative bacteria such as Pseudomonas aeruginosa. - Multidrug resistance in burn leads to life threatening sepsis in burn. - Administer Abx AND monitor effectiveness of antibiotic therapy. - If a burn pt receives aminoglycoside Abx such as Gentamycin, Amikacin, Tobramycin → Monitor for increased creatinine due to increased absorption of meds, which are nephrotoxic.

*Early in the post-burn period, IV pain medications should be given.*

•Initially, opioids are the drugs of choice for pain control [Morphine; Hydromorphone (Dilaudid)]. - Sedative/hypnotics [Haloperidol (Haldol); Lorazepam (Ativan); Midazolam (Versed)] & antidepressants can also be given.

Pruritis (Itching)

•Mild to Severe: can be from skin disorders (e.g. eczema) or systemic disorders such as CRF, diabetes, biliary dz. •Can also be associated with: Allergic responses, Chemical irritation, insect bites, Infestations by parasites (e.g., scabies) •Major complication of pruritus (itching): development of bacterial skin infection, secondary to scratching and allowing bacteria from dirty hands or nails to enter compromised tissue.

Basal cell carcinoma (BCC)

•Most common type of skin cancer •Least deadly; a locally invasive malignancy arising from epidermal basal cells. •Cancerous cells of BCC almost never spread beyond skin. •It appears as a pearly papule with a central crater & rolled waxy border. •Location in the bald spot atop the head that is exposed to outdoor sunlight. - *Exposure to ultraviolet sunlight is a major risk factor*

Factors Affecting Healing

•Nutrition; Blood flow and oxygen •Impaired inflammation; immune response; receiving immunosuppressives (e.g. steroids) •Infection; Wound separation; Foreign bodies; Age

Inhalation injury

•Observe for S/S of resp. distress •Treat quickly and efficiently; 100% humidified oxygen if CO poisoning is suspected •After a burn injury, pts normally are alert. •If pt becomes confused or combative, hypoxia may be the cause. •Hypoxia occurs after inhalation injury & also may occur after an electrical injury. •If an inhalation injury is suspected, administer 100% O2 via a tight-fitting non-rebreather face mask

Care of Burn Patient in ACUTE Phase cont

•Pain - around the clock management •Acute Pain; Chronic Pain Interventions: Drug therapy: Opioid analgesics; Non-opioid analgesics •*Prevent infection: Gowns, masks, gloves, Sterile linen; avoid contact with persons with URI* •Complementary and alternative therapy; Environmental changes for pt comfort & sleep •Early surgical excision under anesthesia to ¯ pain from daily debridement at bedside or during hydrotherapy

Post burn Contracture

•Post burn Contracture can occur & may result in Plantar flexion of the feet due to limited movement of burn area (lower extremities). •Positioning both ankles in dorsiflexed position helps to prevent contractures.

Squamous cell carcinoma (SCC)

•Potential to metastasize & may lead to death if not treated early and correctly •Pipe, cigar, and cigarette smoking contribute to the formation of SCC on the mouth and lips

Contributing Factors of Pressure Ulcers

•Prolonged bedrest; Immobility; Incontinence; Constant perineal moisture; Diabetes mellitus; Inadequate nutrition or hydration; Altered mental status; Peripheral vascular disease •*If a pt is dehydrated & has limited mobility, poor appetite, poor skin turgor, → priority nursing diagnosis is impaired skin integrity rather than fluid volume deficit*

Function of Skin

•Protection, Barrier from bacteria & viruses; Insulation; Prevention of water loss, Thermoregulation; Sensory perception (pain, pressure, touch, temp) and Vitamin D production •Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders.

Care of Burn Patient in ACUTE Phase

•Relieve anxiety, denial, regression, anger, depression •Wound Care •Nutrition (Nutritional assessment, pre albumin levels, large protein requirement, CHO & fats for energy, mega vitamins, TPN, enteral feedings) [ileus is common]. •*Keep NPO because burn injuries frequently result in paralytic ileus. Tell pt that oral fluids could cause vomiting d/t the effect of burn injury on GI tract functioning. Provide mouth care as appropriate to alleviate sensation of thirst.* •*Once pt can eat, ↑ dietary sources of vitamin D & supplemental D3. [especially if pt c/o bone pain] •Burn injury results in acute loss of bone as well as development of progressive vitamin D deficiency because burn scar tissues and adjacent normal appearing skin cannot convert normal quantities of the precursors for vitamin D that is synthesized from ultraviolet sun rays and needed for strong bones.*

Tinea Pedis ("Athlete's foot")

•Risk Factors: poor foot hygiene, tight fitting shoes, hot weather, hx of sweaty feet, non-breathable shoes •People at Risk: elderly, teens, males, diabetics, immunocompromised, PVD pts S/S: Skin becomes thickened and cracked •Poor intake of vitamin B12 may lead to deep inflamed cracks.

Community associated Methicillin resistant staphylococcus aureus (MRSA)

•Risks: IV drug use, skin trauma, previous abx, military, imprisonment, higher BMI, gay men •Management: I & D; Topical antibiotic, oral antibiotic •Prevention: hand washing; avoid exposure; cover abrasions

Scarlet Fever

•Scarlet fever is a syndrome characterized by exudative pharyngitis, fever, & bright-red rash. •*Scarlet fever may follow streptococcal wound infections or burns*, as well as upper respiratory tract infections. •Chest and abdomen show signs of a rash associated with streptococcal infection that occurs within a day, which can extend to cover the whole body. •Desquamation begins at the end of the first week of the infection. •Fever is a physiological result of the infection, not reaction to streptococcal toxin.

Dressing

•Semipermeable film dressings are used on superficial wounds, ulcers, & occasionally on some deep, draining, or necrotic ulcers. •Dry sterile dressings would stick to the wound. •Wet to dry dressings are used when the tissue needs debridement.

Small thermal burns Large thermal burns

•Small thermal burns: Cover with clean, cool, tap water—dampened towel •Large thermal burns: Airway, breathing, circulation •Do not immerse in cold water or pack with ice (this can cause shock) •Remove burned clothing •Wrap in clean, dry sheet or blanket

Eczema Triggers cont.

•Stress: Some pt's eczema s/s get worse when they're feeling "stressed" •Hot/Cold temps & sweating: Most pt's with eczema become itchy or experience a "prickly heat" sensation when they sweat or get too hot. •Infection: eczema can become infected with bacteria or viruses. •Staphylococcus aureus. The herpes virus (fever blisters & cold sores), & certain kinds of fungus (ringworm or athlete's foot) are common triggers.

Signs of Wound Infection

•Strong odor; Color change to dark red or brown •Redness around edges extending to non-burned skin; Texture change •Exudate & purulent drainage; Sloughing of graft •Altered level of consciousness (confusion) •Changes in V/S (tachycardia, tachypnea, temperature instability (hypo or hyperthermia, hypotension) • fluid requirements for maintenance of a normal U/O; Hemodynamic instability; Oliguria •Gastrointestinal dysfunction (diarrhea, vomiting, abdominal distention, paralytic ileus) •Hyperglycemia; Thrombocytopenia •Change in total white blood cell count (above normal or below normal) •Hypoxemia; Metabolic acidosis

Zoster Isolation

•The zoster lesions are contagious, so pt should be in contact isolation. •Corticosteroids ↓ inflammation, which helps the healing process. •The pt can have visitors as long as they do not have an infection that the pt could get & the visitors comply with isolation proto-col. Only visitors who have had chickenpox should be allowed to visit.

Escharotomy

•a surgical procedure used to treat full-thickness (third-degree) circumferential burns, restores circulation to compromised extremities. •Performed to relieve the compartment syndrome that can occur when edema forms under non-distensible eschar in a circumferential third-degree burn. •Escharotomy releases the tourniquet-like compression around the extremity. •Escharotomies are performed through avascular eschar to subcutaneous fat. Distal pulses are expected to return after escharotomy

Cellultitis

•acute bacterial infection/inflammation of dermis & underlying hypodermis (S/C tissue) caused by Staph or strep. S/S: hot, tender, reddened, edematous area with diffuse border resulting from inflammation of S/C tissue; deep red erythema without sharp borders, spreads widely throughout tissue spaces. Untreated cellulitis may progress to gangrene.

Carbunculosis

•formation of carbuncle (deeper infection by Staph Aureus) •A carbuncle is an abscess of the skin & subcutaneous tissue & is an extension of a furuncle. These are more likely to occur in pts with underlying systemic diseases such as diabetes & hematologic malignances & in immunocompromised pts.

Furunculosis

•formation of furuncle "Boil" (acute, red, hot, tender nodule) - Staph aureus folliculitis - Warm, moist compresses increase vascularization & hasten the resolution of the furuncle.

Allergic contact dermatitis

•occurs when skin comes in contact with an allergen the pt is sensitive or allergic to. •findings include skin lesions with well-defined geometric margins.

Melanoma

•pigmented malignant lesions originating in melanin-producing cells of epidermis •most deadly of skin cancers; cause changes in a nevus (mole), including color & borders •*highly metastatic*, has ability to metastasize to any organ, including brain & heart. A person's survival depends on early diagnosis & Tx. •not painful or accompanied by sign of inflammation •Although sun exposure greatly ↑ the risk of melanoma, lesions are most commonly found on the upper back, legs, & on the soles & palms of persons with dark skin

What are the most common sites for the development of non-melanoma skin cancer?

•sun-exposed areas which include the face, head, neck, back of the hands, & arms

Lesions

•traumatic or pathologic loss of normal tissue structure of function •Components of rash are referred to as lesions •Range in size, color, elevation, consistency •(macule, papule, vesicle, plaque, nodule, wheal, vesicle, bulla, pustule)