Problems of the integumentary system (skin cancer and Burns) Ch 49, 50 and 51 Unit 12

ANATOMY, PHYSIOLOGY, AND FUNCTION

• 2 skin layers: epidermis and dermis • 5 major functions of the skin • • Protection, temperature regulation, vitamin D metabolism, sensation, and excretion • • • Supporting temperature regulation, the skin also plays a role through facilitating heat loss or heat conservation through the skin. • • • Vitamin D metabolism is another major function of the skin. • • • Sensation is controlled in the dermis, the location of many nerve receptors that communicate with the central nervous system. • Sweat glands • • Eccrine (body surface) and apocrine (hair follicles) • • • Eccrine sweat glands cover most of body's surface • • • Apocrine sweat glands are present in hair follicles of the armpits and genitalia • Skin • • Epidermis • • • Keratinocytes • • • Keratin • • • Langerhans cells • • • Melanocytes • • Dermis • • • Sebaceous glands • • Subcutaneous tissue This system comprises approximately 15% of the body's total weight and requires 33% of the body's blood volume for optimal function. During times of decreased cardiac output, highly acute illness, and long-term chronic illness, the skin is highly susceptible to damage. • Hair • • Cosmetic importance, reduces heat loss and shields skin from sun exposure • • Present on most of the body and is composed of keratinocytes • • The hair itself is referred to as a root when contained within the follicle, and the portion that emerges from the follicle is referred to as the shaft. • • Extension of the hair shaft cycles between growth and rest. During the hair growth cycle, dead keratinocytes are tightly packed together within the follicle to be pushed toward the skin surface. • • Complete death of a hair follicle results in baldness or alopecia, and causes include heredity, stress, and illness. • Nails • • Protect tips of fingers and toes • • Composed of a hard keratin • • Slow, continuous growth process • • Beneath the skin, the nail matrix houses constantly dividing basale keratinocytes that form the nail root. The nail body refers to the visible portion that adheres to the nailbed. • • Coloration of the nailbed provides information about the perfusion status of the body's most distal locations.

Burns INCIDENCE AND EPIDEMIOLOGY

• 84% of deaths occurs on residential properties • • Smoking and heating equipment • Vehicles account for 2nd largest percentage • 2 common etiologies • • Fire/flame and scald injuries • • • Scald injuries are most prevalent in children under the age of 5, whereas fire/flame dominates all other age groups. • • • Cooking accounts for the largest percentage of fire-related injuries in residential settings followed by heating equipment. • Majority occur between ages of 20-64 years • Men suffer more injuries extinguishing fires and rescuing people • 30% of fire deaths in females occur 70+ years old • People with limited physical and mental abilities are at higher risk of fire death • African Americans and American Indians twice as likely to be injured or killed by home fires • To reduce the incidence of burn injuries, many burn centers are involved in community prevention activities. These activities focus on the higher risk population groups, including children and the elderly

ABCDE rule for skin cancer

• A = asymmetry (one half of the nevus does not match the other • B = border irregularity (edges are ragged, blurred, or notched • C = color variation or dark black color • D = diameter greater than 6mm (size of a pencil eraser) • E = elevation or evolving (ugly duckling)

Parkland Formula

Method of calculating fluid repletion in burn patients.

Skin Cancer Pathophysiology

• Actinic keratoses are considered precancerous lesions. • Squamous cell carcinoma is mostly attributed to cumulative exposure to UVB rays over an extended period of time and is a cancer that arises from epidermal squamous cells (keratinocytes). • Basal cell carcinomas arise from the basement membrane of the epidermis. • The most serious of all skin cancers are malignant melanomas that originate from melanocytes found in the basement membrane of the epidermis.

CURLING'S ULCER

• Acute ulcerative gastro duodenal disease • Occur within 24 hours after burn • Due to reduced GI blood flow and mucosal damage • Treat clients with H2 blockers, mucoprotectants, and early enteral nutrition • Watch for sudden drop in hemoglobin

Full Thickness Burns

• All layers of the skin • Extend into fat, connective tissue, muscle and bone • Waxy white, dry, leather, charred • Less painful-burns pain receptors • Requires grafting-will not heal • Tx-clean, topical agent, skin substitute, excision of eschar, skin grafting

Skin Cancer Actinic Keratosis

• Also called solar keratosis • Epidermal skin lesion • Directly related to sun exposure • Highest prevalence in fair skin, rare in dark skin people • Classified as premalignant but may progress to squamous cell • Erythematous rough macules Occur mainly on face, hands, forearms and upper trunk.

Burn PATHOPHYSIOLOGY

• Anatomical changes • • Functional outcome directly related to depth of burn • • Full-thickness burns resulting in the most significant anatomical skin changes • • Zones-coagulation, stasis and hyperemia • Functional changes • • Burn center • • • Face, hands, feet, genitalia, and perineum • • • Burns over major joints

Skin Cancer Basal Cell Carcinoma

• Arise from Basement membrane of the epidermis. • Rarely metastatic • Superficial broken blood vessels • Affects sun-exposed areas • Can recur

FLUID REMOBILIZATION (end of emergent stage)

• Occurs after 24 hours • Capillary leak stops • Diuresis-fluid shifts from the interstitial spaces into the vascular space • Blood volume increases leading to increased renal blood flow and diuresis • Body weight returns to normal • Hypokalemia

Electrical Burns

-conversion of electrical energy into heat • • injury may occur by direct contact with the source, by an arc between two objects, or as a result of a flame injury caused by ignition of the surroundings. • • Extent of injury depends on the type of current, the pathway of flow, local tissue resistance, and duration of contact

Thermal burn

-dry or moist heat • • can be the result of a flash, scald, or contact with hot objects or flames, and common causes include house fires, car fires, cooking accidents, or injuries as a result of careless smoking

Chemical Burns

-exposure to acid, alkali or organic substances • • burns account for approximately 3% of all burn center admissions and occur in both the industrial and household settings. • • • The three subclasses of chemical burns include acids, alkalines, and organic compounds.

Radiation Burns

-radiant energy being transferred to the body resulting in production of cellular toxins • • are the least common type of burn injury, and the severity of complications is dependent upon the type, dose, and length of exposure.

ASSESSMENT • Physical assessment

After conducting a thorough history, the nurse performs a comprehensive, head-to-toe inspection of the integumentary system. The assessment is conducted in a well-lit area while the patient is minimally clothed. Visual inspection and manual palpation are used to detect abnormalities • After inspection and palpation, document the following: • • Color and temperature • Under normal circumstances, skin color is determined by circulatory status and genetic predisposition. • • Moisture • The level of moisture present in the skin assists the nurse in predicting whether a patient is at risk for skin breakdown. • • Integrity • Skin integrity refers to the degree of intactness of the skin. • • Cleanliness Poor self-care habits such as the inability to clean the skin regularly because of functional, psychological, or economic causes can lead to a variety of problems that range from mild discomfort to full-thickness skin breakdown • • Tissue changes • Many classifications for wound descriptions exist depending on the underlying wound etiology. • • Vascular markings Vascular markings arise from malformations to a blood vessel that have become visible on the skin • • Lesions • When characteristics of lesions are documented, the anatomical location, type of lesion, color, distribution, and arrangement are identified. • Primary lesions may emerge as a direct result of an infectious disease process, an allergic reaction, or an environmental cause. • Secondary lesions describe a transformation of the primary lesion that may be caused by manual disturbance of the site that may develop secondary to itching or picking at the lesion, the treatment method implemented, or advancement of the underlying disease.

Potential Complications of Grafts

Contractures

Emergent stage

airway, Fluid Loss, Cardiac Output, Electrolytes • Secure airway • Support circulation by fluid replacement • Monitor for electrolyte imbalances and treat • Keep the client comfortable with analgesics • Prevent infection through wound care • Maintain body temperature • Provide emotional support

CLINICAL MANIFESTATIONS Emergent stage -Renal

• Changes in renal function are related to decreased renal blood flow • Urine is usually highly concentrated and has a high specific gravity • Urine output is decreased during the first 24 hours • Fluid resuscitation is provided at the rate needed to maintain adult urine output at 30 to 50 mL/hr • Monitor BUN/Cr and Na

Wound Care

• Clean wound • Debridement • • Mechanical • • Hydrotherapy • • Enzymatic • Topical cream

Skin Cancer Precursor Lesions

• Congenital Nevi • • present at birth, color changes from brown to black, varies in size, slightly raised with an irregular surface but fairly regular border. • Dysplastic Nevi • • not present at birth but appear as normal nevi during childhood and become abnormal after puberty. Multiple sites on the body sometimes more than 100 throughout. Often appear on face, trunk, and arms. Pigmentation can be mixtures of tan, brown, black, red and pink. Irregular borders. A dysplastic nevus, occasionally called a Clark's nevus, is an abnormal mole. They can occur at any age and anywhere on the skin. Dysplastic nevi are usually tan, brown, or dark brown in color. They are often wider than an eraser head of a pencil and regularly have indistinct borders • Lentigo Maligna • • tan or black patch on the skin that looks like a freckle. Grows slowly but becomes mottled, dark, thick and nodular. Usually seen on one side of the face of an older adult

Acute/ phase-Nutrition and infection

• Continued assessment and maintenance of the cardiovascular and respiratory system • Infection-wound, pneumonia, tetanus toxoid • Nutrition-weight daily without dressings or splints and compare to pre-burn weight • • A 2% loss of body weight indicates a mild deficit • • A 10% or greater weight loss requires modification of calorie intake • Pain management

DIAGNOSTIC STUDIES AND NURSING CONSIDERATIONS

• Culturing and laboratory studies • • Tissue culturing Methods of tissue collection vary depending on the lesion's characteristics but include the swab culture, needle aspiration culture, and biopsy. • • Laboratory studies In addition to tissue surveillance by way of culturing, additional laboratory and diagnostic evaluations may be ordered to ensure appropriate treatment for patients who are suspected of having a more serious skin infection. These include: •Complete blood count (CBC) to evaluate for infection. •Chemistry screening to evaluate protein status (albumin) and accumulation of waste products in the blood. •Blood cultures to identify whether the organism has entered the circulatory system. •Doppler ultrasound to evaluate blood flow through vessels. • • Fungal infections •Fungal skin lesions are often manifested as erythematous coloration, well-defined edges, scaling, pustules, papules, plaquelike distribution, and satellite lesions. • • Bacterial infections •Bacterial skin conditions may range from a mildly uncomfortable pustule on a hair follicle to insidious infections that destroy the skin and fascia of an entire extremity. • • Viral infections •Viral skin lesions often have a vesicular appearance and may be highly contagious. • Skin biopsy • • Key diagnostic tool • • Allows for microscopic examination of skin conditions or infections • • Shave, punch, and excisional biopsies • • Biopsy is indicated for ulcers and nodules so that all skin layers may be scrutinized

Skin Cancer Malignant Melanoma

• Deadly Skin Cancer • Accounts for 4% of skin cancer but causes 79% of skin cancer deaths • Highest incidence is in Caucasians' • More than 6mm in size and are asymmetric • Considered benign until they penetrate the dermis • Poor prognosis if they are on the hands, feet and scalp

Tissue Damage Burns

• Determined by looking at extent of the burn and depth of the burn • Classified as mild, moderate or major • Superficial, partial thickness and full thickness

Stages of Care

• Emergent-injury through fluid resuscitation • Acute-diuresis to closure of wound • Rehabilitative-wound closure to highest level if heath restoration

Superficial Burns

• Epidermal layer only • Like a sunburn • Heals in 3-6 days, no scarring • Tx-clean, topical agent, pain relief

Partial Thickness Burns

• Epidermis and dermis • Superficial or deep • Blisters or pale waxy white • Skin no longer functions • Severe pain and weeping of fluid • Heals in 14 to greater than 21 days • Tx-clean, topical agent, pain relief, possible graft if deep

Risk Factors for Non-Melanoma Skin Cancer

• Fair skin, blue or green eyes, blond or red hair • Family history • Sun exposure or UV radiation (natural or artificial) • Radiation treatment • Occupational exposures to coal, tar, arsenic or radium • Severe sunburns as a child

FLUID SHIFT Emergent stage

• First hemostasis and vasoconstriction, then dilation • Blood vessels dilate and leak fluid into the interstitial space • Known as third spacing or capillary leak syndrome • Causes decreased blood volume and blood pressure • Occurs within the first 12 hours after the burn and can continue to up to 36 hours

CLINICAL MANIFESTATIONS Emergent stage -CV

• Fluid loss and shock • Obtain a baseline EKG • Monitor for edema, measure central and peripheral pulses, blood pressure, capillary refill and pulse oximetry • Monitor for loss of flow to extremities and restrictive injuries

Rule of Nines

• For partial and full thickness (2nd and 3rd degree) burns • Head, trunk, arms, legs and perineum get percentages to determine extent of burn • Figure % of total body surface area (TBSA) • Not accurate on adults who are obese, short or very thin • Head & Neck = 9% • Each upper extremity (Arms) = 9% • Each lower extremity (Legs) = 18% • Anterior trunk= 18% • Posterior trunk = 18% • Genitalia (perineum) = 1%

Risk factors for Malignant Melanoma

• High number of moles or large moles • Fair skin, freckles, blond hair and blue eyes • Family history (close relative) • Exposure to sun or UV radiation (tanning beds) • Over 50 • Past history of melanoma

FLUID / Electrolyte IMBALANCES Emergent stage

• Hypovolemia • Metabolic acidosis • Hyperkalemia • Hyponatremia • Hemoconcentration (elevated blood osmolarity, hematocrit/hemoglobin) due to dehydration

Infection

• Immunological • • High risk for infection and sepsis • • Function loss • • • Protection, altered immunological defenses, and open wounds • • • As a result of these alterations, patients with burns are in a constant state of systemic inflammatory response syndrome (SIRS). • Sepsis • • Leading cause of death after surviving first 24 hrs • • Infection control is a high priority • • • Infection control is a high priority when dealing with the patient who has suffered a burn injury. • • • Approximately 28% to 65% of burn patients die as a result of sepsis.

Burn Healing

• Inflammation-immediately following the injury • • Platelets aggregate and fibrin deposited and vasoconstriction causing hemostasis • • Local vasodilation and capillary permeability follows • • Monocytes converted to macrophages and consume pathogens, dead tissue • Proliferation-2-3 days post burn to reepithelialization • • Granulation tissue begins to form • • Reepithelialization occurs covering wound (can be via cell migration or surgical) • Remodeling-years

Fluid Resuscitation Emergent stage

• Infusion of IV fluids is needed to maintain sufficient blood volume for normal CO • Clients with burns involving 15% to 20% of the TBSA require IV fluid • Purpose is to prevent shock by maintaining adequate circulating blood fluid volume • Severe burn requires large fluid loads in a short time to maintain blood flow to vital organs • Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital • Diuretics should not be given to increase urine output. Change the amount and rate of fluid administration. Diuretics do not increase CO; they actually decrease circulating volume and CO by pulling fluid from the circulating blood volume to enhance diuresis. • Rapid fluid replacement is needed to prevent shock • Parkland formula-warmed LR at 4ml/kg x %burned • Half given in 1st 8 hours of injury and rest over next 16 hours • Fluid resuscitation is based on individual client needs (evaluation of urine output, cardiac output, blood pressure, status of electrolytes) • Colloid solutions, such as albumin, or synthetic plasma expanders (Hespan, Plasma-Lyte), may be used after the first 24 hr of burn recovery. • Maintain urine output of 30 mL/hr (0.5 to 1.0 mL/kg/hr).

CLINICAL MANIFESTATIONS Emergent stage -Airway

• Inhalation injuries • • Inspect the mouth, nose, and pharynx • • Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators • • Change in respiratory pattern may indicate a pulmonary injury • • Progressive hoarseness, brassy cough, drool or difficulty swallowing • • Expiratory sounds that include audible wheezes, crowing, and stridor • Upper airway edema and inhalation injury are most common in the trachea and mainstem bronchi • Auscultate these areas for wheezes • If wheezes disappear, this indicates impending airway obstruction and demands immediate intubation

DIET

• Initially NPO • Begin oral fluids after bowel sounds return • Do not give ice chips or free water lead to electrolyte imbalance • High protein, high calorie

Skin Cancer Squamous Cell Carcinoma

• Malignant tumor of the epithelium of the skin or mucous membranes • Occurs on areas of frequent sun exposure • Aggressive and metastasizing growth • Invades surrounding tissue • Ulcerates, bleeds and is painful when it grows • May occur from pre-existing skin lesions (scars, burns, actinic keratosis) Starts as a small firm red nodule.

Major burns

• More than 25% TBSA in adults less than 40 years of age • More than 20% TBSA in adults more than 40 years of age • More than 10% TBSA full thickness burns • Injuries to face, eyes, ears, hands, feet or perineum • High voltage electrical injury • Inhalation injury or major trauma • Burn shock • Cardiac rhythm abnormalities • Compartment syndrome • Airway injury • Carbon monoxide poisoning • AKI • Illeus and Curling's ulcers • Opportunistic infections

Skin Cancer Epidemiology

• Non-melanoma skin cancers include basal cell and squamous cell carcinomas • Approximately 2.2 million people are diagnosed each year with a form of non-melanoma skin cancer. • Basal cell carcinomas are the most common form of cancer occurring in human beings, accounting for approximately 75% of all diagnosed skin cancers. • Actinic keratosis is diagnosed in more than 10 million people per year worldwide and represents the most common skin condition treated by dermatologists.

Wound management

• Nonsurgical management: removal of exudates and necrotic tissue, cleaning the area, stimulating granulation and revascularization and applying dressings. Debridement may be needed • After burn wounds are cleaned and debrided, topical antibiotics are reapplied to prevent infection • Standard wound dressings are multiple layers of gauze applied over the topical agents on the burn wound

Burns INTRODUCTION

• Only 64 burn centers in the U.S. • Majority of patients receive initial care at local hospitals prior to transfer to a burn center • Essential for health-care providers to have a basic understanding • • Regarding stabilization • • Initial management of this patient population •Burn patients are optimally managed at a burn center where they have the advantage of an interprofessional team of health-care providers skilled in the specialized treatment of burn injuries.

Moderate burns

• Partial thickness 15-25% of TBSA • Full thickness less than 10% not involving eyes, ears, face, hands, feet, perineum

AGE-RELATED SKIN CHANGES

• Performance of the 5 basic functions of skin is less efficient as body ages • Skin becomes increasingly fragile • Longer to heal • Temperature regulation and excretion become less efficient • Subcutaneous tissue decreases • Fat Pad production decreases • Seborrheic keratosis • Senile lentigines (liver spots) • Cherry angiomas • Elderly individuals also develop a decreased perception of injury because fewer sensory receptors are present in the skin layers. Hair and nail growth rates decrease as well.

GOALS end of emergent stage

• Prevent complications (contractures) • Vital signs hourly • Assess respiratory function • Tetanus booster • Anti-infective • Analgesics • No aspirin • Strict surgical asepsis • Turn q2h to prevent contractures • Emotional support

LOCAL AND SYSTEMIC SIGNS OF INFECTION- GRAM NEGATIVE BACTERIA

• Pseudomonas, Proteus • May led to septic shock • Conversion of a partial-thickness injury to a full-thickness injury • Ulceration of health skin at the burn site • Erythematous, nodular lesions in uninvolved skin • Excessive burn wound drainage • Odor • Sloughing of grafts • Altered level of consciousness • Changes in vital signs • Oliguria • GI dysfunction such as diarrhea, vomiting • Metabolic acidosis

Medications

• Respiratory medications-bronchodilators and mucolytics • Topical antimicrobials (see table in ATI book)- • • Silver nitrate 0.5% • • Silver sulfadiazine 1% (Silvadene) • • Mafenide acetate (Sulfamylon) • • Bacitracin • Pain medication • • Morphine, fentanyl (Sublimaze) • Sedatives • • Midazolam (Versed), propofol (Diprivan), and nitrous oxide

Objectives

• Review of anatomy and physiology of the integumentary system. • Describe components of a focused history and physical assessment of a patient with alterations of the integumentary system. • Describe laboratory and diagnostic data specific to the integumentary system. • Describe physiological changes that occur in the integumentary system with aging. • Outline management of the patient with skin neoplasms and burns. Address pathophysiology (definition, etiology, prognosis, and chronicity), clinical manifestations, medical management and potential complications. • Develop a nursing care plan for the patient with skin neoplasms and burns. Include a focused assessment, nursing and collaborative diagnoses, goals, nursing interventions and a means of evaluating care.

ASSESSMENT screenings

• Screening for malignancies of the skin • • Nevi, or moles Nevi, or moles, are circumferential, benign epidermal or dermal growths that are less than 1 cm in size and more common in patients with lighter skin tones. During skin assessment, the nurse evaluates these sites for cancerous cell changes. • Braden scale For patients in acute and long-term care settings, research supports using a proven risk assessment tool such as the Braden scale to predict risk for subtle skin changes caused by immobility, moisture, and inadequate nutrition. • Hair assessment • • Cleanliness, quantity, quality, and distribution • Nail assessment • • Color, shape, consistency, and lesion formation Systemic illness, local infection, or occupational exposures contribute to variations in nail color, shape, consistency, and lesion formation.

Integumentary system

• Skin, hair, and nails • Comprises the protective coating that guards the body from injury • Largest and most visible organ • Careful assessment of skin, hair, and nail abnormalities will sustain the protective shield

Classification of Melanoma

• Superficial Spreading Melanoma: most common; flat, scaly and crusty come from nevi • Lentigo Melanoma: comes from precursor lesion, appear in shades of brown • Nodular Melanoma: may look like a blood blister, arise in unaffected skin • Acral Lentiginous Melanoma: more common in dark skin, found on palms of hands and soles of feet. Women and men in their 50-60's

Minor Burns

• Superficial burns • Partial thickness less than 15% TBSA • Full thickness less than 2% excluding eyes, ears, face, hands feet, perineum and joints • Treated outpatient • • Report impaired healing • • Wound care • • Pain management

Extent of Burn-TOTAL BODY SURFACE AREA (TBSA)

• Superficial burns are not involved in the calculation • Rule of Palm- size of the patients hand is 1% • Lund and Browder Chart is the most accurate because it adjusts for age (currently controversial) • Rule of nines divides the body - adequate for initial assessment for adult burns

Management Malignant Melanoma

• Surgical excision • • Skin cancers with well-defined margins (surrounding structures are not involved) can be treated with surgical excision. • Curettage and electrodesiccation • • Curettage and electrodesiccation: this treatment method is appropriate for low-risk, smaller lesions. • Mohs' micrographic surgery • • Considered the "gold standard" for the treatment of non-melanoma skin cancers, Moh's micrographic surgery is a highly specialized surgical approach completed only by surgeons specifically trained in this procedure. • Photodynamic therapy • • This is a noninvasive procedure that applies light therapy following an application of a topical photosensitizing agent. • Cryotherapy • • Liquid nitrogen is used for cryotherapy. • Radiotherapy • • Radiotherapy is appropriate for use in patients who are poor surgical candidates because of their health or the site and extent of the tumor. • Topical chemotherapy • • Topical chemotherapy with 5-fluorouracil is used in the treatment of multiple actinic keratoses or for superficial widespread basal cell carcinoma that would take multiple surgical procedures for complete removal.

CLINICAL MANIFESTATIONS Emergent stage -GI

• Sympathetic stimulation causes reduced GI motility and paralytic ileus • Auscultate the abdomen to assess bowel sounds which may be reduced • Monitor for n/v and abdominal distention • Clients with burns of 25% TBSA or who are intubated generally require a NG tube inserted to prevent aspiration and removal of gastric secretions

GRAFTING

• Temporary skin coverings • • Allograft (homograft) - Skin is obtained from human cadavers that is used for partial- and full-thickness burn wounds. • • Xenograft (heterograft) - Obtained from animals, such as pigs, for partial thickness burn wounds. • • Amnion - Obtained from human placenta; requires frequent changes. • • Synthetic skin coverings - Used for partial-thickness burn wounds. • Grafting-permanent • • Autografts • • • Sheet graft - Sheet of skin used to cover wound • • • Mesh graft - Sheet of skin placed in mesher so skin graft has small slits in it; allows graft to cover larger areas of the burn wound • • Artificial skin - Synthetic product that is used for partial- and full-thickness burn wounds (healing is faster) • • Cultured epithelium - Epithelial cells cultured for use when grafting sites are limited

Burns Assessment

• The type of burning agent • The duration of contact • Depth of burn • Location of burn and TBSA • Inhalation damage • Carbon monoxide inhalation • Shock

TYPES OF BURNS

• Thermal -dry or moist heat • • Thermal burns can be the result of a flash, scald, or contact with hot objects or flames, and common causes include house fires, car fires, cooking accidents, or injuries as a result of careless smoking • Electrical-conversion of electrical energy into heat • • Electrical injury may occur by direct contact with the source, by an arc between two objects, or as a result of a flame injury caused by ignition of the surroundings. • • Extent of injury depends on the type of current, the pathway of flow, local tissue resistance, and duration of contact • Chemical-exposure to acid, alkali or organic substances • • Chemical burns account for approximately 3% of all burn center admissions and occur in both the industrial and household settings. • • • The three subclasses of chemical burns include acids, alkalines, and organic compounds. • Radiation-radiant energy being transferred to the body resulting in production of cellular toxins • • Radiation burns are the least common type of burn injury, and the severity of complications is dependent upon the type, dose, and length of exposure. • Burns are generally classified in terms of etiology, depth of tissue damage, total body surface area (TBSA) involved, and severity.

Burns Labs

• White blood cell (WBC) count - identifies infection • Hgb and Hct - may be decreased due to blood loss • Serum electrolytes - imbalances such as hyperkalemia or hyponatremia • Blood glucose - elevated due to stress response • ABGs - slight hypoxemia and metabolic acidosis • Total protein and albumin - low due to fluid loss • BUN - elevated due to enhanced metabolism of proteins

Functional changes Burn PATHOPHYSIOLOGY

• • Burn center • • • Face, hands, feet, genitalia, and perineum • • • Burns over major joints • The location of a burn injury plays an important part in determining the level of care required and in the functional changes that may result.

ASSESSMENT • History

• • Demographics • Key physiological skin changes in the elderly include increased fragility caused by thinning of skin layers, decreased subcutaneous tissue, decrease in excretion from sebaceous and sweat glands, and fewer sensory receptors and immune system cells. • • • Vitiligo describes a confined type of depigmentation caused by the loss of melanocytes at a specific body area. • • • Albinism is an autosomal recessive condition leading to generalized depigmentation caused by a lack of melanin production despite having a normal melanocyte to keratinocyte ratio. • • Personal history • • • Comorbid conditions • Advancing comorbid conditions that affect other body systems can frequently lead to the emergence of wounds, skin and nailbed discoloration, textural changes, and hair distribution changes. • • • Medications • Commonly used medications frequently have side effects that impact skin appearance and function. • • • Family history • After discussing the patient's current skin conditions and personal history, the nurse inquires about family history. • • • Environmental factors • Environmental factors: occupational exposures, lifestyle habits, and sun exposure impact skin integrity.

Anatomical changes Burn PATHOPHYSIOLOGY

• • Functional outcome directly related to depth of burn • • Full-thickness burns resulting in the most significant anatomical skin changes • • Zones-coagulation, stasis and hyperemia • The zone of coagulation is the area that had the most contact with the heat source and is the location of the most severe damage. The tissue undergoes protein coagulation and eschar is often present, and the patient often reports no pain within this area because all nerve cells are destroyed. • The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. • The outermost area is termed the zone of hyperemia and is generally an area of increased blood flow in an effort to bring key nutrients for tissue recovery.

Surgical Management Malignant Melanoma

• • Treatment is excision with 5-mm margin of unaffected tissue including a sentinel lymph node (the node closest to the site of cancer) biopsy • • Incurable • • Median survival of 7.5 months following diagnosis • Complications • • Physical complications of the treatments • • Psychosocial aspects In addition to the physical complications of the treatments, the psychosocial aspects of skin cancers can have far-reaching effects on both the patient and family

REHABILITATIVE PHASE OF BURN INJURY

•Begins with wound closure and ends when the client returns to the highest possible level of functioning •Provide psychosocial support •Assess home environment, financial resources, medical equipment, prosthetic rehab •Health teaching should include symptoms of infection, drugs regimens, f/u appointments, comfort measures to reduce pruritus

DEBRIDEMENT

•Done with forceps and curved scissor or through hydrotherapy (application of water for treatment) •Only loose eschar removed •Blisters are left alone to serve as a protector - controversial •Fascial excision or fasciectomy-sacrifices lymphatic and fat tissues (for extensive or full thickness burns), cut off layers until it bleeds

POST CARE OF SKIN GRAFTS

•Maintain dressing-Use aseptic technique •Immobilize •Graft should look pink if it has taken after 5 days, begin ROM at 5 days •Skeletal traction may be used to prevent contractures •Elastic bandages may be applied for 6 mo to 1 year to prevent hypertrophic scarring