NUR 317 Exam 3 (Skin & Tissue Integrity ptt & outline/ATI Med Surg CH 73, 74, 75)

Corticosteroids - MOA

Triamcinolone, betamethasone. Reduce secondary inflammatory response of lesions and suppresses cellular division/proliferation.

hypodermis (subcutaneous tissue)

composed of fatty layer of skin that contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells.

Pressure Injury

localized injury to skin and underlying tissue resulting from unrelieved pressure, shear, friction

Dehiscence

A separation of wound layers, usually of a surgical incision. Those prone to dehisence include: Patients at risk for wound healing (poor nutritional status, infection, obese patients, abdominal surgical wounds - patient often reports feelings as though something has given way. Increase in serosanguineous drainage from a wound in the first few days after surgery may indicate dehiscence.

Pathogenesis of Pressure Ulcers

(1) Pressure intensity: causes *localized ischemia* (>15-32mmHg) (2) Pressure duration/length of time with circulation (3) Tissue tolerance: Ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structure's ability for the skin to tolerate pressure

Classification of wounds by degree of CONTAMINATION

*Clean*: uninfected; no inflammation; respiratory, GI, GU, genital tracts not entered. *Clean/contaminated*: uninfected; no inflammation; but respiratory, GI, GU, genital tracts have been entered. *Contaminated*: open, traumatic wounds or surgical wounds involving a major break in sterile technique that show evidence of inflammation. *Infected*: old, traumatic wounds containing dead tissue and wounds with evidence of a clinical infection (e.g., purulent drainage).

What should a nurse assess regarding wound drains?

*Drain*: assess number, type, location with respect to wound, placement, security, condition of collecting equipment. *Drainage*: assess character & measure amount (volume).

Types of Burns

*Dry heat injuries*: open flames and explosions. *Moist heat injuries*: contact with hot liquid or steam. *Contact burns*: hot metal, tar, grease. *Chemical burns*: exposure to caustic agent. Cleaning agents in home (drain cleaner, oven cleaner, bleach) and agents in the industrial setting (caustic soda, sulfuric acid) can cause chemical burns. *Electrical burns*: electrical burn current passes thorugh body, can cause severe damage, including loss of organ fxn, tissue destruction with subsequent need for amputation of a limb, and cardiac or respiratory arrest. *Thermal burns*: clothes ignite from heat or flames that electrical sparks produce. *Flash (arc) burns*: contact with electrical current that travels through the air from on conductor to another. *Conductive electrical injury*: touching electrical wiring or equipment. *Radiation burns*: result from therapeutic treatment for cancer or from sunburn.

Unstageable/unclassified: Full thickness skin or tissue loss - depth unknown

*Full thickness* tissue loss. Depth *obscured* by *slough* and/or *eschar* (eschar prevents granulation). Slough/eschar removed --> Stage 3 or 4. Do NOT remove stable eschar on heel.

Category/Stage 4 Pressure Ulcer

*Full-thickness tissue loss* with *exposed/directly palpable bone, tendon, muscle, fascia, ligament, cartilage* Slough and/or eschar may be visible. Epibole, undermining and/or tunneling *often* occurs

Category/Stage 3 Pressure Ulcer

*Full-thickness tissue loss* with*Subcutaneous fat* visible and granulation tissue and epibole (rolled wound edges) are often present. Presents clinically as deep crater with or without undermining of adjacent tissue. Slough and/or eschar may be present Undermining and tunneling may occur fascia, muscle, tendon, ligament, cartilage and/or bone NOT exposed.

Risk factors for development of pressure ulcers

*Immobility*: results in inability to relieve pressure by changing position. *Malnutrition*: results in weight loss which reduces the padding between skin and bones. *Hypoproteinemia*: precipitates foermation of edema which makes skin more susceptible to pressure. *Fecal and urinary incontinence*: causes maceration (tissue softened by prolonged wetting and soaking) which makes skin more susceptible to pressure. *Decreased mental status*: results in inability to respond to pain from increased pressure by changing position. *Diminished sensation*: results in inability to respond to pain from increased pressure by changing position. *Advanced age*: results in... --loss of lean body mass --thinning of the epidermis --decreased elasticity of the skin due to loss of collagen. --decreased vascularity --reduced skin turgor --increased dryness and scaliness --decreased pain perception

Escharotomy

*Incision* through eschar *relieves pressure* from constricting force of fluid buildup under circumferential burns on the extremity or chest and *improves circulation*

Classification of wounds by DESCRIPTIVE QUALITIES

*Laceration*: tearing apart of tissues resulting in irregular wounds edges. *Abrasion*: Scraping or rubbing the surface of the skin by friction. *Contusion*: blow from a blunt object resulting in swelling, discoloration, bruising, and/or ecchymosis. *Incision*: cutting the skin with a sharp instrument. *Puncture*: penetration of the skin and, often, the underlying tissues by a sharp instrument.

Nursing care of the GI system related to Burns

*NG tube insertion*: reduce aspiration risk, bowel decompression, gastroparesis Monitor stool, vomitus, gastric secretions for *BLOOD*. Assess for *hypomobility and tolerance of feedings.*

Category/Stage 2 Pressure Ulcer

*Partial thickness tissue loss* involving *epidermis* and *dermis*. Presents clinically as abrasion, blister, or shallow pink/red crater; without slough or bruising.

Deep tissue pressure injury

*Purple* or *maroon* area (nonblanchable) of *discolored intact skin* or *blood-filled blister* due to damage of underlying soft tissue from *pressure* and/or *shear*. Area may be preceded by tissue that is *painful, firm, mushy, boggy, warmer or cooler* as compared to adjacent tissue. May be difficult to detect in dark skin tones.

MEDS for bacterial infections

*Superficial skin infections*: use topical antibacterial cream/ointment. *Extensive bacterial skin infections* (involving lymphatic system; if cellulitis is present): use systemic antibiotic (cephalosporins or penicillins). If Penicillin/cephalosporin *ALLERGIES*: then tetracycline, erythromycin, azithromycin, tobramycin. Skin lesion with *MRSA*: IV vancomycin or PO linezolid, clindamycin

Factors influencing pressure ulcer formation and wound healing (think T-PAIN)

*Tissue Perfusion*: O2 fuels cell fxns essential healing process. Patients with PVD at risk for poor tissue perfusion due to poor circulation. *Psychosocial impact* of wounds: body image changes impose stress. *Age*: affects all phases of wound healing. Decrease in functioning of macrophages--leads to inflammatory response, delayed collagen synthesis, and slower epithelialization. *Infection*: prolongs inflammatory phase, delays collagen synthesis, prevents epithelialization, increases production of proinflammatory cytokines. *Nutrition*: need calories, protein, vitamin C & A, zinc, fluids. Nutritional maintenance = 1500 kcal/day

MEDS for fungal infections

*Yeast/dermatophyte infections*: topical cream/powder. Ex: *clotrimazole* cream applied to infected skin 2x/day for 1-2 weeks after the lesion no longer present/as Rx by provider. Skin must be clean & dry before applying topical ointments/creams.

Risk factors for psoriasis

-*Infections* (severe streptococcal throat infection, Candida infection, upper respiratory infection). -*Skin trauma* (recent surgery, sunburn). -*Genetics* -*Stress* (related to overstimulation of the immune system) -*Seasons* (warm weather improves manifestations) -*Hormones* (puberty or menopause) -*Meds* (lithium, beta-blocker, indomethacin) -*Obesity*

Describe the types of wound drainage.

-*Serous*- clear, watery plasma -*Purulent*- thick, yellow, green, tan or brown -*Serosanguineous*- pale, pink, watery; mixture of clear and red fluid -*Sanguineous*- bright red; indicates active bleeding

Staging systems for pressure ulcers

-*Stage 1*- Intact skin with nonblanchable redness of a localized area over a bony prominence. -*Stage II*- Partial-thickness skin loss involving epidermis, dermis, or both -*Stage III*- Full-thickness with tissue loss- SubQ Fat visible but NOT muscle, tendon/lig, or bone -*Stage IV*- Full-thickness tissue loss with exposed bone, tendon, or muscle. - Osteomyelitis risk

Health promotion and disease prevention for Burns

-Operable/adequate placement and number of fire extinguishers and smoke alarms. -Emergency numbers near phone. -Family exit and meeting plans for fires. No one should ever re-enter burning building. -Stop, drop, roll -store matches/lighters out of reach/sight of children/certain adults. -Reduce setting on water heaters to 48.9 C (120 F) -Annual professional inspection and cleaning of chimney and fireplace. -Turn handles of pots and pans to side or use backburners. -Don't leave hot cups on edge of counter -cover electrical outlets -keep flammable objects away from heat sources -wear gloves when handling chemicals and keep out of reach of children. -wear protective clothing during sun exposure/use sunscreen -avoid using tanning beds - avoid smooking in bed when under influence of alcohol or sedating meds. -do not smoke or have open flames in room where O2 is in use. -never add flammable substance to open flame (gas, lighter fluid, kerosene)

Wound care for Burns

-Premedicate w/ analgesic -Remove previous dressing -Assess for odors, drainage, discharge -Assess for sloughing, eschar, bleeding, and new skin-cell regeneration. -Cleanse wound throroughly, remove all previous ointments. -Assist with debridement: mechanical, hydrotherapy, chemical -surgical asepsis while applying thin layer of topical antibiotic ointment and cover it with a dressing.

Infection prevention related to Burns

-Protective environment -Restrict plants and flowers -Limit vistors -Monitor for infection/report to HCP -Client-dedicated equipment -Administer Tetanus toxoid -Administer antibiotics (monitor pk/trough levels) -Strict asepsis during wound care

Physical assessment findings

-Scaly patches. -Bleeding stimulated by removal of scales. -Pruritic skin lesions primarily on the scalp, elbows and kness, sacrum, and lateral areas of extremities (psoriasis vulgaris). -Pitting, crumbling nails.

Restoration of mobility

-maintain correct body alighment, splint exteremities, facilitate position change (prevent contractures) through passive and active ROM -monitor areas at risk for pressure ulcers (heels, sacrum, back of head, etc.)

Nursing care for Minor Burns

-stop burning process -cover with clean cloth for protection -cleanse with mild soap and tepid water -provide warmth -provide analgesia -antimicrobial ointment -flush chemical burns with large volume of water -apply dressing -educate family on not using greasy lotions or butter and how to monitor for signs of infection -teach about evidence of infection -need for tetanus shot

4. After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the surgeon. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1 & 4

Pain/comfort management for Burns

1) *Monitor pain and effectiveness* of pain treatment. 2) *Avoid routes other than IV* during resuscitation phase due to decreased absorption from other routes. 3) Use *IV opioid analgesics* (morphine, hydromorphone, fentanyl or anesthetics [ketamine, nitrous oxide]) 4) Monitor *respiratory depression* (opioids) 5) *PCA* appropriate in some clients; helps manage pain; clients have sense of control. 6) *pain med prior to dressing changes* and procedures 7) Use *nonpharmacologic* method for pain control 8) *Restful environment/nonpainful touch/promote rest* 9) Involve client in decision making (decrease anxiety) 10) Provide relief for *itching*; PO antipruritics 11) *Pat* rather than scratch.

Fluid replacement for Burns

1) *Third spacing (capillary leak syndrome)*: a continuous leak of plasma from vascular space --> interstitial space; results in electrolyte imbalance and hypotension. 2) *Initiate IV access* w/ large-bore needle. Central venous/intraosseous catheter if burn covers large area. 3) Administer *half* of total 24-hr IV fluid volume within the *first 8 hr* from time burn occurred and *remaining volume* over *next 16 hr*. 4) Infuse *NS or Lactated ringers* (isotonic crystalloid solns) 5) Infuse colloid solutions (*albumin or synthetic plasma expanders*) after first 24 hours of burn recovery. 6) Monitor *Vital Signs* 7) Assess for *fluid overload*: edema, engorged neck veins, rapid and thready pulse, lung crackles, wheezes. 8)*daily weights* 9) Monitor *urine output hourly* for color, spec. gravity, protein, and the ensure output of 30mL/hr. 10) Prepare to administer *blood products* 11) Monitor for manifestations of *shock* (confusion, increased cap refill time, urine output < 30 mL/hr, rapid elevations in temp, decreased bowel sounds, BP avg/low)

Nursing assessment/care of respiratory system for Burns

1) Assess *RR and resp. depth*. Monitor *chest expansion* to ensure dressings don't restrict movement. 2) Upper airway *edema*: pronounced after 8 to 12 hr after beginning of fluid resuscitation. *Crowding, stridor, or dyspnea* requires *nasal/oral intubation*. 3) Provide *humidified supplemental O2* 4) *Support* the *airway* & *ventilation*. Mechanical ventilation and paralytic meds (atracurium or vecuronium) can become necessary of PaO2 is < 60 mmHg. 5) Monitor/maintain *chest tubes* 6) Perform *chest physiotherapy* 7) have client *Cough, deep breath, use IS* 8) *Suction* Q1 hr/PRN. Consider need for additional analgesics.

Postprocedure - bacterial infection

1) Bathe daily using antibacterial soap. 2) Do not squeeze bacterial lesion but remove crusted exudate so med can penetrate. 3) Apply warm compresses 2x daily to furuncles/areas where cellulitis is present. 4) Use good HH at all times. 5) Do not share personal items. 6) Position clients on BR so they get optimal air circulation to the area and to avoid occlusive dressings or garments.

5. What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place waterproof bag near bed. 5. Position angiocatheter over wound.

4, 2, 3, 5, 1

7. Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1. Frequent position changes 4. Using an incontinence cleaner 6. Applying a moisture barrier ointment

10. When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers 5. To immobilize area

1. To relieve edema 3. To improve blood flow to an injured part

15. Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1. Use a transfer device (e.g., transfer board) 3. Have head of bed flat when repositioning patient 5. Raise head of bed 30 degrees when patient positioned supine

2. Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid.

1a, 2d, 3b, 4c

9. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 9. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2. Providing support to abdominal tissues when coughing or walking 4. Reduction of stress on the abdominal incision

13. What does the Braden Scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing

2. Risk factors that place the patient at risk for skin breakdown

Severity of burns and overall health of the client

A client with chronic illness has a greater risk of complications and a worse prognosis.

Lund and Browder Method

A more exact method of estimating the extent of burn by the % of surface area of specific anatomic parts, particularly the head and legs.

1. When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

Nutritional support for burn(s)

> Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia. > Increase protein intake to prevent tissue breakdown and promote healing. > Provide enteral therapy or total parenteral nutrition (TPN) if necessary due to decreased gastrointestinal motility and increased caloric needs. > Calorie Count daily

Vitamin A client education

Avoid exposure to sun or artificial UV light. Use reliable forms of birth control because medication is teratogenic. D/c use and notify provider if pregnancy occurs.

Rehabilitative phase of burn care

Begins when most of burn area has healed Ends when client achieves highest level of functioning possible. Priorities include psychosocial support; prevention of scars and contractures; resumption of activities, including work, family, and social roles. This phase can last for years.

Emergent Phase of burn care

Begins with injury. Continues for 24 to 48 hours. Priorities: securing the airway, supporting circulation and organ perfusion by fluid replacement, managing pain, preventing infection through wound care, maintaining body temp, providing emotional support.

Braden Scale

Braden 6 areas of assessment: sensory perception, moisture, activity, mobility, nutrition, friction & shear. Braden Q can range from 6-23. Score of *16 or less* is *high risk* for development of pressure ulcers.

Vitamin D analogs

Calcipotriene, calcitriol. MOA: Prevent cellular proliferation and regulate skin cell division. Nursing actions: Monitor for itching, irritation, erythema, hypercalcemia (elevated blood sugar, muscle weakness, fatigue, anorexia). Client education: Limit sun exposure due to increased risk of developing skin cancer. Adhere to proper application. Do not put on face. Monitor for cancerous lesions.

Wound care inside the acute care setting

*Frequent Assessment* *Wound Assessment* --Debridement (Mechanical, autolytic, chemical, or surgical/sharp) --Culture / cleansing of wounds --Moist wound healing --Dressing selection --Nutritional support --Off-load pressure --Client education

Exicisional biopsy

*Larger* and *deeper specimen* obtained, and *suturing required*

Classification of lesions

*Mild*: < 5% of body surface area. *Moderate*: 5 - 10% of BSA. *Severe*: < 10% of BSA

MEDS for viral infections

*Topical treatment* with *acyclovir*, *valacyclovir*, *famciclovir* (decreases # of active viruses on surface of skin; redues discomfort with herpetic infection/lesion). Topical antiviral meds less effective against *recurrent infections*

Nurse actions in the event of evisceration of patient wound.

The nurse immediately places sterile damp gauze to extruding tissues to reduce chance of bacterial invasion/drying of tissues. Contacts surgical team. Does not allow anything by mouth (NPO). Observes for signs and symptoms of shock. Prepares patient for emergency surgery.

Excision of wound tissue or surgical debridement

Removal of thin layers of necrotic tissue until bleeding occurs, which indicates viable tissue. Can be replaced throughout the restoration process.

Biopsy

Removal of tissue sample by *excision* or *needle aspiration* for cytological exam. Confirms or rules out *malignancy*. Performed under *local anesthesia*

Diagnostic procedures for Burns

Renal scans, computed tomography, US, bronchoscopy, MRI, indirect calorimetry, evaluation of burn depth using Indocyanine green video angiography and laser Doppler imaging.

Nursing diagnoses associated with impaired skin integrity and wounds.

Risk for infection. Imbalanced nutrition: Les than body requirements. Acute or chronic pain. Impaired skin integrity. Risk for impaired skin integrity. Impaired physical mobility. Ineffective peripheral tissue perfusion. Impaired tissue integrity.

Identify differences in assessment of impaired skin integrity in patients with dark skin tones.

To assess a dark-skinned patient for presence of category/stage 1 pressure ulcer: Assess skin in well-illuminated setting; use natural light or halogen light. *Skin Color* may remain unchanged/non-blanchable; area of skin may be lighter than rest of skin; eggplant or purple-blue color. *Temperature*: warm or cool *Appearance*: edema may occur with induration and appear taut and shiny. Tissue resilience (boggy or mushy). *Palpation*: sensitive or tender to touch; hard or lumpy on palpation.

Wound grafting

Treatment of choice for burns covering large areas of body.

True of false: A wound does not move through the phases of healing if it is infected.

True

Skin Diagnostic Studies - Preprocedure

Use standard precautions when collecting/handling specimens. Most will be collect be the nurse or provider.

Severity of burns & percentage of total body surface area (TBSA)

Use standardized charts for age groups to identify the extent of the injury and calculate medication doses, fluid replacement volumes, and caloric needs.

Nursing care for hypothermia related to burns

Use warm inspired air, a warm room, warming blankets, adn warmers for infusing fluids.

Mannitol

Used following some electrical burns when obstruction of renal tubules with protein myoglobin hinders urine output

Synthetic skin coverings

Used for partial thickness burn wounds. Made from plastic or silicone and are usually clear. They allow for wound visualization and reduce pain.

Drains

Used with large amount of drainage. Maybe sutured in place. Suction or low pressure (or self-suction). Examples include JP drain (self-suction) and Penrose drain.

Autolytic Debridement

Uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of WBCs & natural enzymes that are present in wound fluids. Wound gel: coat wound bed with gel. Examples: transparent film and hydrocolloid dressings.

Shear

Sliding movement of skin and subcutaneous tissue while underlying muscle and bone remain stationary. Capillaries/microcirculation damaged as a result.

Tertiary intention (delayed primary) wound healing

Wound purposely left open for initial granulation (~4 to 6 days). Closure delayed until risk of infection is resolved. Example: Contaminated wounds or those that require observation for signs of inflammation.

Primary Intention

Wound that is closed by epithelialization with minimal scar formation; edges are approximated (closed); his can be with stitches, or staples, or skin glue (like Derma bond), or even with tapes (like steri-strips). e.g. Surgical or knife wound

Secondary Intention

Wound that is left open until it becomes filled by scar tissue; chance of infection is greater. e.g. Loss of tissue from burns, pressure ulcers, and severe laceration

Implications for Healing by Secondary Intention

Wounds heal by granulation tissue formation, wound contractions, and epithelialization.

Wound care outside the acute care setting

Wounds like their own environment: Dressing changes interrupt healing. Aim to change wound care 2-3 times/week. Routine dressing changes in home: clean technique. Disposal of contaminated dressings (local regulations). Physical conditions of the home. Presence/ability of caregivers (re-assess weekly). Life cycle accommodations / accommodate for age. Lifestyle considerations. Basic element of trust: intimate view of family dynamics. Time of intense vulnerability for client and family.

Inter-professional collaboration for wound management

You will want to take a holistic approach to wound management. You will want to work with the dietician, the wound care nurse, and the pharmacist to ensure that all patient needs are met. AN individualized plan of care must be developed for each patient, taking into account age, nutrition, present medical conditions, and other contributing factors.

Risk factors for dermatitis

-External skin exposure to allergens. -Internal exposure to allergens and irritants. -Stress (eczematous dermatitis). -Genetic predisposition (eczematous dermatitis). -Specific cause not always known.

Nursing care for the Urinary system related to Burns

1) Indwelling cath. 2) Monitor I&O 3) Monitor for red-tinged urine (indication of damage to RBCs or muscles) 4) Glycosuria (due to breakdown of glycogen as part of stress response)

Client education for wound grafting

1) Keep extremity elevated. 2) Observe wound for/Report manifestations of infection. 3) Continue to perform ROM exercise & work with PT to prevent contractures. 4) Perform wound care

Lab tests during Fluid Remobilization

Starts at about 24 hr; diuretic stage begins at 48 to 72 hr after injury *Hgb & Hct*: DECREASED (hemodilution) due to fluid shift from interstitial place --> vascular fluid. *Na*: remains DECREASED due to renal & wound loss. *K*: DECREASED due to renal los & movement back into cells (hypokalemia). *WBC count*: initial INCREASE then DECREASE with left shift. *Blood glucose*: ELEVATED due to stress response *ABGs*: slight hypoxemia and metabolic acidosis *Total protein & albumin*: LOW due to fluid loss

Meds for dermatitis

Steroid therapy, antihistamines, topical immunosuppressants.

Classification of wounds by DEPTH

Partial-thickness: involves only epidermal and dermal layers of skin. Full-thickness: involves the epidermal and dermal layers of skin, subcutaneous tissue and, possibly, muscle and bone.

Classification of wounds by SEVERITY of injury.

Superficial: involves only epidermal layer of skin. Penetrating: involves penetration of the epidermal and dermal layers of skin and deeper tissues or organs.

Wound types

Surgical and Traumatic Pressure Ulcers Lower-Extremity/Vascular Neuropathic Burns Oncology related

Wound Types

Surgical and Traumatic. Pressure Ulcers. Lower-Extremity/Vascular. Neuropathic. Burns. Oncology related.

Topical immunosuppressants

Tacrolimus, pimecrolimus Therapeutic use: treatment of eczematous dermatitis that has been resistant to glucocorticoid treatment. Relieves inflammation. Nursing actions: Instruct on application. Monitor for erythema, burning sensation. Avoid occlusive dressings. Client education: Avoid use if infection present. D/c use when rash clear. Avoid direct sunlight/use of tanning beds.

Vitamin A

Tazarotene; slows cellular division, reduces inflammation, causes sloughing of skin cells.

Nursing interventions for psoriasis

Teach lifestyle modifications and coping strategies. Discuss treatment plan with the client. Client education: Use comfort measures (baths with emollients, oatmeal baths, emollient creams) to soften scales. Do not scratch or pick lesions.

Norton Scale

Physical and mental condition, activity, mobility, and incontinence

Mechanical Debridement

Physical removal of debris by (irrigation high-pressure irrigation and pulsatile high-pressure lavage), hydrotherapy or wet-to-dry dressing application (take guaze, moisten with saline, put in wound, gently touch all surfaces of wound, 24 hours then take out).

CMS and reimbursement

Pressure Ulcer location and stage must be documented on admission & coded (DRG coverage) Medicare Reimbursement / Recognizes: Pressure ulcers Surgical wounds Stasis ulcers No acute care reimbursement for hospital acquired Stage III or IV

Biologic skin coverings for Burns

Temporarily promote healing of large burns. Promote retention of water and protein and provide coverage of nerve endings, thus reducing pain. Types: allograft, xenograft, amnion, cultured skin, artificial skin

What the the functions of the integument (skin)?

Protection Thermoregulation Fluid & Electrolyte balance Sensation Metabolism Communication/identification Vitamin D synthesis.

Purpose of Dressings

Protects wound from microorganisms. Goal: promoting moist wound healing. Facilitate wound healing process. Aids in hemostasis (pressure dressing). Provide systemic support to reduce existing and potential cofactors. Promotes thermal insulation.

Evisceration

Protrusion of visceral organs through a wound opening. Emergency, requires surgical repair.

Psychological support for client and family

Provide emotional support. Assist with coping. Client might require antianxiety meds. Address body image with client/discuss concerns about altered appearance. Assist client through stages of grieving. Peer support.

Palmar Method

Quick method to approximate scattered burns using the palm of the client's hand. The palm of the hand (including the fingers) is equal to 1% TBSA.

Blanchable erythema

Reddened area that turns pale under applied light pressure. Blanchable erythema is NOT a Stage I pressure ulcer.

Palmoplantar pustulosis

Redenned hyperkeratotic areas (accelerated maturation of epidermal cells) due to inflammatory disorder. Plaques form, pustules turn brown, peel, form a crust on the palms of the hands and soles of the feet. Course of the disease is cyclic.

Punch biopsy

Removal of a *small plug* of tissue approximately *2 - 6 mm* is removed with a specific cutting instrument, *with* or *without sutures* to close the site. Most skin biopsies are obtained using the punch.

Surgical Debridement

Removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument

Chemical Debridement

Can be accompished with use of a topical enzyme preparation, Dakin's solution, or sterile maggots. Topical enzymes induce changes in the substrate resulting in the breakdown of necrotic tissue. Depending on the type of enzyme used, the preparation digests or dissolves the tissue. Dakin's solution breaks down and loosens dead tissue in a wound.

Skin culture and sensitivty

Can be done on sample of purulent drainage from skin lesion. Should be done prior to starting antimicrobial therapy. Preliminary results available within 24-48 hr. Final results in 72 hr.

Pressure Ulcer Scale for Healing (PUSH)

Categorizes with respect to surface area, exudate, and type of ulcer/wound tissue. Measured over time provides an indication of the improvement or deterioration in healing.

Contact dermatitis

Caused by direct exposure to allergen, chemical, mechanical irritant. Appears as well-demarcated, localized rash. Distribution varies.

Atopic dermatitis

Chronic rash, caused by allergens or chronic skin disease. Development of thickened areas of skin along with scaling and desquamation. Pruritis (can be intense). Distribution: face, neck, upper torso along with skin folds (antecubital, popliteal)

Preventing wound infection includes?

Cleaning and removing nonviable tissue. A moist environment supports the movement of epithelial cells and facilitates wound closure.

Tar prepartions

Coal tar and tars made from trees (juniper, birch, and pine) suppress cellular division/proliferation and reduce inflammation. Nursing actions: Monitor skin for irritation. Instruct on proper applications. Client education: Tar applications can cause stinging, burning, straining of the skin and hair. Due to odor and staining, apply this product at night and cover areas of the body with old PJs, gloves, socks.

Potassium hydroxide (KOH) test

Confirms *fungal skin lesion*. Microscopic exam of *scales scraped off* lesion, mixed with *KOH*. Specimen *positive* for fungus if presence of fungal *hyphae (threadlike filaments)*.

Impaired muscle and joint mobility related to burns

Deep burns can limit movement of bones and joints. Scar tissue can form and cause shortening and tightening of skin, muscles, and tendons (contractures). Nursing actions: > Assist with active/passive ROM exercises at least 3x BID. > Encourage Neutral positions with limited flexion & use of Splints. > Encourage AMBULATION asap. > Use compression dressings for up to 24 months to increase mobility and reduce scarring.

Wood's light examination

Detects color changes in clients with light skin tones or who have areas for hypopigmentation. Room darkened, UV light used to produce specific colors to reveal skin infection, discern between dermal and epidermal lesions, differentiate normal skin from hypo- and hyperpigmented areas.

Nonspecific eczematous dermatitis

Development of *thickened* areas of skin. Can appear *dry* or *moist & crusted*. *Pruritis*. *Symmetrical* involvement anywhere on the body.

Exfoliative psoriasis

Displays as erythema & scaling from a severe inflammatory reactions with no obvious lesions. The reaction can cause dehydration and hypothermia and hyperthermia.

Airway injury from burns

Effects might not manifest for 24 to 48 hours. Effects: progressive hoarseness, brassy cough, difficulty swallowing, drooling, copious secretions, adventitious breath sounds, and expiratory sounds that include audible wheezes, crowing, and stridor. Nursing actions: Support the *airway & ventilation*, and administer *supplemental O2* Client education: *Perform airway management* (deep breathing, coughing, and elevate HOB).

Preprocedure nursing actions for biopsy

Ensure client signed consent form. Inform them scar can form.

Intraprocedure nursing actions for a biospy

Establish a sterile field. Place the tissue sample in a container containing appropriate solution, label, send to lab. Apply pressure to biopsy to control bleeding. Place sterile dressing over site.

Deep tissue injury - evolution

Evolution may include thin blister over dark wound bed. May further evolve, become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Nutrition for wound healing

F-CCAPZ Fluids Calories C-Vitamins A-Vitamins Protein Zinc

Identify the factors that contribute to the development of pressure ulcers

Factors affecting intensity and duration of pressure. Impaired mobility/decreased acitivty. Impaired sensory perception. Altered LOC. Intrinsic factors (age, nutrition, vascular perfusion) and extrinsic factors (increased moisture, increased friction, and increased shear forces) that affect Tissue Tolerance.

Exudate

Fluid, pus, cells, or other substances discharged from cells or blood vessels slowly through small pores or breaks in cell membrane. Need to describe amount, color, consistency, odor

Diascopy

Glass slide or lens pressed down over skin area; tested for blanchability. Painless, used to determine whether lesion is vascular (inflammatory), or nonvascular (nevus) or hemorrhagic (petechiae or purpura). Hemorrhagic and nonvascular lesions do not blanch, but inflammatory lesions do

Granulation tissue

Healthy, viable pink to beefy red; remaking of healthy cells; composed of new blood vessels; indicates wound healing.

Fluid imbalances related to Burns

Hypovolemic shock possible with inadequate fluid replacement. Excessive or rapid replacement can lead to HF. Nursing actions: > Assess fluid volume status. Daily weights. Document I&O. > Mointor labs > Administer IV F & E's > Monitor indications of inadequate perfusion, confusion, hypotension, decreased urine output. > Monitor for indications of excessive hydration (bounding pulse, lung crackles, persistent edema, venous distention)

Health promotion and prevention of dermatitis

If cause not identified, avoidance therapy used. *Do NOT scratch affected areas* (can cause secondary skin infections). Use products (soap, laundry detergent, cosmetics) that *do not contain fragrance*. *Avoid* use of *fabric softener dryer sheets*. *Wash skin thoroughly after exposure* to irritants. Apply *cool, damp compresses* to rash to decrease inflammation. Use *colloidal oatmeal baths* to relieve itching.

Extravasation

Infiltration of IV fluid - results in inflammatory reaction in the tissue. Necrosis or blisters present.

Lab tests during Resuscitation Phase

Initial fluid shift (occurs in the first 12 hr & continues for 24 to 36 hr) >*CBC* with differential >*Glucose*: elevated (due to stress) >*BUN*: elevated (due to fluid loss >*Hct & Hgb*: elevated (hemoconcentration) due to the loss of fluid volume and fluid shift into interstitial space (third spacing) >*Sodium (Na)*: decreased due to 3rd spacing (hyponatremia) >*Potassium (K)*: increased due to cell destruction (hyperkalemia) >*Chloride (Cl)*: increased due to fluid volume loss and Cl reabsorption in urine. >*Carboxyhemoglobin*: more than 10% strongly indicates smoke inhalation. >*Plasma lactate*: elevated if the client has cyanide toxicity. >*other*: total protein & blood albumin (decreased); ABGs (possible metabolic acidosis), liver enzymes, UA, and clotting studies.

3 phases of burn care

1. Emergent 2. Acute 3. Rehabilitation

Polymixin B-bacitracin

Instructions: apply Q2-8 hr to keep burn moist. Advantages: Bacteriostatic vs Gram + & painless, easy to apply. Disadvantages: Hypersensitivity

Category/Stage 1 Pressure Ulcer

Intact skin with non-blanchable erythema (redness). Discoloration of the skin (except purple or maroon), warmth, edema, harness or pain may also be present.

Classification of wounds by CAUSE

Intentional: wound that is the result of planned therapy. Unintentional: wound that is the result of unexpected therapy.

Tissue tolerance: extrinsic and intrinsic factors

Intrinsic factors: ability of dermis to assist in redistributing pressure (Poor nutrition, increased age and low BP, decrease tissue tolerance). Extrinsic factors: Shear, friction, moisture

Postprocedure for fungal infections

Keep skin clean & dry. Turn/reposition frequently.

Infection (Complications of Wound Healing)

Local clinical signs include: -Redness. -Purulent (thick; yellow, green, tan, brown) drainage. -Change in odor, consistency (thickness), color of drainage. -Periwound warmth. -Pain. -Swelling. -Fever. -Increase in WBC count.

Hematoma

Localized collection of blood underneath tissue; appears as swelling, change in color, sensation, or warmth that often takes on bluish discoloration. Dangerous if near major artery/vein.

Pressure Injury

Localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Can present as intact skin or an open ulcer; may be painful. Occurs as result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear also may be affected by micro-climate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.

Sepsis/wound infection from burns

MOST COMMON CAUSE OF DEATH FOLLOWING BURN INJURY! Assess discoloration, edema, odor, drainage. Assess for fluctuations in temp & HR. Obtain specimens for wound culture. Administer antibiotics. Monitor labs (watch for anemia and infection). Use surgical asepsis with dressing changes. Educate client and family about importance of skin, muscles, and tendons.

Periwound areas

Maceration: whitish, wrinkled appearance; pressence of excessive moisture. Rash:may indicate fungal infections. Erythema: may mean infection.

Vitamin A nursing actions

Medication is contraindicated during pregnancy. Monitor for localized reactions, burning sensation, inflammation, and desquamation of the skin. Instruct on proper application.

Gosnell Scale

Mental status, continence, mobility, activity, nutrition.

Cytotoxic medications for psoriasis

Methotrexate, aitretin. MOA: Reduce turnover of epidermal cells; used for severe, intractable cases. Nursing actions: Monitor Liver (LFT) & Renal Function Tests (RFTs). ADRs: Methotrexate - bone marrow suppression (leukopenia, thrmbocytopenia, anemia). Contraindications: during pregnancy; can cause fetal death, congenital anomalies. Client education: avoid alcohol; advise clients to monitor for fever, sore throat, increased bleeding or bruising, and fatigue; these meds can decrease effectiveness of contraceptives.

Tzanck smear

Microscopic cytology exam completed after extracting cells from *base* of lesion. Reveals *multinucleated giant cells* to confirm lesion is viral.

Laser light therapy

Mild to moderate psoriasis to target lesions directly and decrease exposure to surrounding skin.

What % of the body is skin?

15% of the bodies weight The body's largest organ

6. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing

2. Ice bag

Severity of burns and presence of other injuries

fractures or other injuries increase the risk of complications

Cultured skin

grown from small specimen of epidermal cells from unburned area

Induration

harending of tissue because of edema or inflammation. Dimple appearances gives you hint something is occurring under tissue,

Expected indications for Inhalation of Carbon Monoxide (from burns in an enclosed area)

headache, weakness, dizziness, confusion, erythema (pink or cherry red skin), and upper airway edema, followed by sloughing of the respiratory tact mucosa.

Complications of Wound Healing

hemorrhage, hematoma, infection, dehiscence, evisceration

Dermis

composed of thick layers of skin. Contains collagen and elastic fibers, nerve fibers, blood vessels, sweat and sebaceous glands, and hair follicles. Identity- gives feature to skin. Also, site of plastic surgery.

Narrow-band ultraviolet B light therapy

implemented w/o med application; requires fewer treatments

Severity of burns and location on the body

in areas where the skin is thinner, there is more damage to underlying tissue (any part of the face, hand, perineum)

Necrotic Tissue

nonviable tissue; has to be removed or fall off

Bioburden

degree of microbial contamination

Skin layers (outer to inner)

epidermis, dermis, hypodermis (subcutaneous tissue or fatty tissue)

Cultured epithelium

epithelial cells cultured for use when grafting sites are limited

Rule of Nines

quick method to approximate the extent of burns by dividing the body into multiples of 9. The sum = TBSA

Psoriasis vulgaris

reddened, thickened skin with silvery-white scales with bilateral distribution

Shave biopsy

removal of only the part of the lesion that is *raised above* the surrounding tissue using a scalpel or razor blade with *no suturing*.

Major burns

require emergency treatment at the closest facility, then immediate transfer to a burn center. Clients who meet any one of the following criteria are considered to have a major burns, even if the depth and TBSA percentage would place them in a lower category. -Full-thickness burns > 10% TBSA -Or partial-thickness burns > 25% TBSA. -Age > 60 years. -Presence of a chronic cardiac, pulmonary, or endocrine condition. -Presence of electrical burn injury -Presence of inhalation injury or other complicated injury. -Burns to the eyes, ears, face, hands, feet, or perineum.

Mesh graft

sheet of skin in which a mesher has created small slits, so the graft can stretch over large areas of the burn

Sheet graft

sheet of skin used to cover the wound

Expect findings for Inhalation damage

singed nasal haor, eyebrows, and eyelahses; sooty sputum; hoarsness; wheezing; edema of the nasal septum; smoky smelling breath. Indications of impending loss of airway: hoarsness, brassy cough, drooling or difficulty swallowing, and audible wheezing, crowing, and stridor.

Allograft

skin donations from human cadavers for partial and full thickness burn wounds

Xenograft

skin from animals (pigs) for partial thickness burn wounds

Autograft

skin from another area of clients body

Stage 2 should never be used to describe?

skin tears, tape burns, incontinence-associated, dermatitis, maceration, or excoriation.

Severity of burns and burn depth

superficial, partial, full, deep full thickness

During the initial (resuscitation) phase (from the time of injury to 12 to 48 hr later) following a major burn, _________ manifestations are expected findings.

sympathetic nervous system (tachycardia, increased RR, decreased GI motility, Increased Blood glucose)

Artifical skin

synthetic product for faster healing of partial- & full-thickness burns

Nonblanchable erythema

the ulcer appears as defined area of redness that does not blanch (become pale) under applied light pressure.

Severity of burns and causative agents

thermal, chemical, electrical, or radioactive

Steroids for dermatitis

topical, intralesional, systemic (hydrocortisone, betamethasone, triamcinolone, prednisone) Reduce secondary inflammatory response of lesions. Nursing actions: monitor for adrenal suppression. Instruct client about proper application. Client education: 1) if using steroids for long time, taper doses when discontinuing medication. 2) Avoid using topical steroids on lesions that are infected. 3) Warm, moist dressings can be used over topical application to increase absorption of medication. 4) Avoid the use of occlusive dressings over rash after applying topical steroid meds.

Antihistamines for dermatitis

topical, systemic (diphenhydramine, certirizine, fexofenadine). Use: relief of redness, pruritis, edema. Nursing actions: Monitor for urinary retention with use of systemic meds. Client education: Product can cause photo-sensitivity. Avoid operating heavy machinery and driving while taking systemic antihistamine. Take systemic form at bedtime, as product can cause drowsiness.

Minor burns

treated at scene and followed up at a local ED. Full-thickness burns of less than 2% TBSA. Or partial thickness of less than 10% TBSA.

Moderate burns

treated at the snce,e then the cleint transported to burn center or specialized medical facility. Full-thickness of 2%-10% TBSA. Or partial-thickness of 15%-25% TBSA.

Artificial skin

two layers of skin made from beef collagen and shark cartilage

Biosynthetic dressings

used for superficial partial-thickness burns or donor site dressing. Allows exudate to drain through the wound.

Wound vacuum assisted closure (V.A.C.)

uses negative pressure to support healing. Depth of >1/2 cm and granulating. 125 mm standard intermittent: use continuous to hold dressing in place. Wound is typically < 20% necrotic tissue. Minimal to heavy exudate: edema reduction and fluid removal: Removes exudate and stretched epithelial cells to enhance healing. Angiogenesis, granulation tissue formation, and reduction in bacterial bioburden. Never use over exposed blood vessels, organs, nerves. Computerized unit with open-celled foam sponge. Change every 24 hours and 5 days.

Severity of burns and age

young clients and older adults have less reserve capacity to deal with a burn injury. Skin thins with aging, so more damage to underlying tissue can occur.

8. Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4. A dressing that forms a gel that interacts with the wound surface

Paralytic ileus

Monitor bowel sounds/abdomen distention. Provide NG decompression until motility returns. Report paralytic ileus to provider (indicator of systemic infection).

Nursing assessment/care of CV system for Burns

Monitor central & peripheral pulses, cap. refill, pulse ox., invasive/noninvasive BP, ECG changes, edema

Compartment syndrome

Monitor peripheral circulation on affected extremties; report adverse findings to HCP

Bates-Jensen Wound Assessment Tool

Monitors wound healing and yields data useful for plan-of-care development. Running tool of how well you are caring for a wound.

Corticosteroids - nursing actions

Observe skin for thinning, striae, or hypopigmentation with high-potency corticosteroids. Instruct client on proper application.

Classification of wounds by SKIN INTEGRITY

Open: break in skin integrity or mucous membrane. Closed: no break in skin integrity or mucous membrane.

14. On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage II 2. Category/stage IV 3. Unstageable 4. Suspected deep-tissue damage

3. Unstageable

3. When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound

4. Cleansed wound

Photochemotherapy and UV light (PUVA therapy)

A *psoralen photo-sensitizing* medication (methoxsalen) is administered followed by *long-wave ultraviolet A (UVA)* to *decrease proliferation* of epidermal cells. Methoxsalen given *PO 1 hr before* UV treatments. Treatments given *2 - 3x/week*, avoiding consecutive days. Nursing actions: Monitor *client response*. Ensure client wears *eye protection* during treatment and for 24 hr following a treamtent (indoors and outdoors). Client education: Notify provider of *extreme redness, swelling, or discomfort*. Long-term effects include premature skin aging, cataracts, and skin cancer. Regular eye exams and sunscreen.

Pressure Ulcer stats

According to the Agency for Healthcare Research and Quality there are more than 17,000 lawsuits related to pressure ulcers annually. Reported incidence of pressure ulcers • in long-term care varies widely in the literature, ranging from 3.6% to 59.0% • in terminally ill nursing home residents it is reported as high as 54.7%

Silver sulfadiazine 1%

Apply a thin layer with a clean glove. Advantages: usually pain free. Effective vs. Gram -, + and yeast Disadvantages: can cause *transient neutropenia*; *sulfa allergy*; pentrates eschar minimally; can cause *gray or blue green discoloration*; *decreases granulocyte formation*

Postprocedure - Viral lesion

Apply compress of *Burow's solution (aluminum acetate in water)* for *20 min, 3x/day* to promote formation of crust/healing. 1) avoid tight, retrictive clothing that irritates lesion. 2) allow lesion to dry between treatments 3) avoid lying on lesion to promote circulaton and comfort 4) use good HH 5) avoid sharing personal items

Corticosteroids client education

Apply high-potency corticosteroids as prescribed to prevent adverse effects and take periodic medications vacations. The provider can recommend warm, moist, occlusive dressings of plastic wrap (gloves, plastic garments, booties) after applying the topical med. These can be left up to 8 hr each day. Avoid application of high-potency med on face or into skin folds. Med can be applied to the scalp. Monitor for adverse effects of the med (hypopigmentation, atrophy).

Medications for Burns

Apply topical agents (antimicrobial creams, ointments, solutions). > Silver nitrate 0.5% > Silver sulfadizaine 1% > Mafenide acetate > Polymixin B-bacitracin > Gentamicin topical > Mannitol > Others: antianxiety, antipuritic meds; antimicrobial ointments; electrolye replacement

Silver nitrate 0.5%

Apply with gauze dressing. Advantages: Reduces fluid evaporation; bacteriostatic; inexpensive. Disadvantages: Does not penetrate eschar; stains clothes and linen; *depletes Na and K*.

Deep full thickness burns

Area involved: *All layers of skin*; extends to *muscle, tendon, bones*. Appearance: *Black*; no blisters; no edema; eschar *hard & inelastic*. Sensation/healing: *no pain*; heals within *weeks to months*; *scaring*; *grafting*. Examples: high voltage/prolonged electrical burns; flames.

Full thickness burns

Area involved: *entire epidermis & dermis*; *can extend* to subQ; *nerve damage*. Appearance: *red, black, brown, yellow, or white*; No blisters; *severe edema*; eschar *hard & inelastic*. Sensation/healing: sensation *minimal/absent*; heals within *weeks to months*; *scaring*; *grafting* Example: Scalds; grease, tar, chemical, or electrical burns; prolonged exposure to hot objects.

Deep-partial thickness

Area involved: *entire epidermis* & *deep into dermis* Appearance: *Red to white*. Blisters rare. *Moderate* edema. *Eschar soft and dry*. Sensation/healing: Painful/*sensitive to touch*. Heals within *2 - 6 weeks*. *Scaring likely*. *Possible grafting*. Example: Flame; scalds; grease, tar, or chemical burns; prolonged exposure to hot objects.

Superficial-partial thickness

Area involved: *entire epidermis*; *some* parts of the *dermis*. Appearance: Pink to red. *Blisters*. *Mild to moderate* edema. No eschar. Sensation/healing: Painful. Heals within *3 weeks*. No scarring, but *minor pigment changes*. Example: Flash flame, scalds, brief contact with hot object.

Superficial-thickness burns

Area involved: *epidermis*. Appearance: Pink to red. No blisters. Mild edema. No eschar. Sensation/healing: Painful/tender. Sensitive to heat. Heals within *3 to 6 days*. No scaring. Example: Sunburn. Flash burn (sudden intense heat).

Biologic agents for psoriasis

Alefacept Etanercept Infliximab Adalimumab Ustekinumab Therapuetic use: first line treamtent for moderate - severe plaque psoriasis that suppress immune function, suppress the simulation of keratinocytes. Nursing actions: 1) Evaluate for latent TB & Hep B virus. 2) Inspect prefilled syrgine for particles or discoloration. 3) Rotate injection sites, do not rub after administration. 4) Protect med from light. 5) Implement infection control measures (client @ risk for immunosuppression). Client education: 1) do not take if pregnant/breastfeeding. 2) properly administer subQ med. 3) Report manifestations of infection. 4) Treatment is lifelong, and there is an increased risk of cancer. 5) Do not receive any live vaccines while taking the medication.

Moist dressing theory

Allen and Kock- Pioneers Odland- Developed some observational research- blister healing Winter- Formed the basis for Moist dressings

Gentamicin topical

Aminoglycoside anti-infective agent (*advantage: kills bacteria*) Disadvantages: *Nephrotoxic* (monitor kidney fxn) & *Ototoxic* (monitor for hearing loss weekly)

Mafenide acetate

Apply 2x daily. Advantages: *penetrates eschar* and goes into underlying tissues; Bacteriostatic vs gram neg and pos Disadvantages: painful to apply/remove; can cause *metabolic acidosis*

Acute phase of burn care

Begins 36 to 48 hours after injury when fluid shift resolves. Ends with closure of wound. Priorities: assessment & maintainence of the CV, respiratory, and GI systems (including nutrition); wound care; pain control; and psychosocial interventions.

Eschar

Black, brown, or tan necrotic tissue. Needs to be removed before healing care proceed.

Hemorrhage

Bleeding from a wound site. Observe all wounds closely, risk of hemorrhage is great during first 24 to 48 hours after surgery or injury.

Indocyanine green video angiography & laser Doppler imaging

Both show areas of high & low tissue perfusion

Indications for biopsy

Commonly performed to establish exact diagnosis or to rule out diseases (cancer). Evidence of skin lesion can include an area of discoloration that is thickened, thinned, raised, flat, rough, painful, open, dry, and/or itchy.

Intraprocedure for bacterial or viral specimens

Express material from lesion by lifting or puncturing crusted/scabbed area over lesion with small-gauge sterile needle or 0.9% sodium chloride and a sterile cotton swab. Culturette tubes: specific for specimen collect. Specimen obtained for viral culture immediately placed on ice and sent to lab.

Infection rates; External v. Surgical wound

External: 2-3 days Surgical: 4-5 days

Amnion

From human placenta; requires frequent changes

Fasiciotomy

Incision through eschar and fascia relives tissue pressure when escharotomy alone does not

Severity of burns & involvement of the respiratory system

Inhalation of deadly fumes, smoke, steam, and heated air can cause respiratory failure or airway edema. Carbon monoxide poisoning also can occur, especially if the injury took placed in an enclosed area.

Signs of Internal Hemorrhaging

Looking for distention or swelling of the affected body part. A change in the type and amount of drainage from a surgical drain. Signs of hypovolemic shock (e.g., increased pulse, decreased blood pressure, cool, clammy skin)

Interprofessional Care of Burn Wounds

Referrals: dietician, social worker, psych, PT, OT, ST, RT, case manager,home health nursing care, vision and hearing specialists, prosthetics

Intraprocedure - Fungal specimen

Requires sufficient quality of scales collected using wooden tongue depressor to scrape skin and place specimen in clean container. Punch biopsy: performed with inconclusive results due to deeper fungal infection. Specimen must be properly labeled and delivered to lab promptly.

The nursing process and wounds: Assessment

Pain Appearance of Wound: --Approximation of wound edges. --Color of the wound and surrounding area. --Signs of dehiscence or evisceration. --Wound drainage. --Sutures and staples.

Diabetic Neuropathic Wound

Result of damage to nerve structures. Impaired perfusion, susceptibility to infection, trauma. Usually callous present. Location (Plantar surface of foot).

Venous Stasis

Result of impaired venous blood return-valve issues. Blood and serum pool and break through skin. Plasma or straw colored exudate seeps out before it breaks through skin. Common in diabetes, methadone users, CHF (different mechanism, same injury). Moderate to copious exudate, edema, fibrous slough, irregular poorly defined edges. Location: between ankles and knees.

Expected findings for hypovolema & shock

Results from fluid shifts from intercellular & intravascular space --> Interstitial space. Findings: hypotension, tachycardia, decreased CO

Nursing Diagnoses related to skin

Risk for infection Imbalanced nutrition: less than body requirements Acute or chronic pain Impaired physical mobility Impaired skin integrity Risk for impaired skin integrity Ineffective peripheral tissue perfusion Impaired tissue integrity

Methods to assess burns

Rule of nines, lund and browder method, palmar method. Others include indocyanine green video angiography and laser Doppler imaging

Postprocedure considerations for a biospy

Post-biopsy comfort usually relieved by mild analgesics. Monitor biopsy for bleeding. Check biopsy site daily. Report excessive bleeding or evidence of infection to provider. Dressings removed after 8 hr. Use tap water and 0.9% sterile sodium chloride to clean biopsy site of dried blood or crusts. Apply an antibacterial topical med to prevent infection (if prescribed). Return to provider for removal of sutures in 7 - 10 days. It could take several days for results.

Best Practice in Summary

Prevent and manage infection. Cleanse wound. Remove nonviable tissue. Maintain appropriate level of moisture. Eliminate dead space. Control odor. Eliminate or minimize pain. Protect wound and peri-wound skin.

Epidermis

Several thin layers; contains the following: Melanocytes: produce melanin, a pigment that gives skin its color and protects it from damaging effects of UV radiation. Keratinocytes: produce keratin, a water-repellent protein that gives the epidermis its tough, protective quality.

Slough

Stringy substance attached to wound bed that is soft, yellow, or white, moist tissue.

Kennedy Terminal Ulcer

The Kennedy Terminal Ulcer is an unavoidable skin breakdown or skin failure that occurs as part of the dying process. Research is limited but the literature suggests that Kennedy Terminal Ulcers are typically pear-shaped, red/yellow/black, similar in appearance to an abrasion, and tend to occur suddenly in the sacral/coccygeal region not long before death.

Blister

represents partial-thickness skin loss involving the epidermis, dermis or both and is ALWAYS STAGE 2/ulcer is superficial

Risk factors for burns for older adults

Thinner skin --> Higher risk for damage to subQ tissue, muscle, CT, bone Chronic illness (Diabetes, CV disease) --> higher risk for complications from burns

Nursing Actions for Wound grafting

1. Maintain immobilization of graft sites. 2. Elevate extremities. 3. Provide wound care to donor site. 4. Administer analgesics. 5. Monitor for infection before and after applying skin coverings or grafts. 6. Determine clients level of pain and provide measure to control donor site pain.

Fungating Malignant Wounds

A cancerous lesion involving the skin which is open and may be draining. Often diagnosis late. Often pungent odor (Dakin's solution, Flagyl, Charcoal dressings)

11. What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

1. Debridement

Assessment/evaluation of pressure intensity and duration

Check for reactive hyperemia (whether or not patient blanches). Blanching: fingertip pressure/area turns lighter in color/redness returns when finger is removed = transient hyperemia (engorgement) and no permanent damage. Nonblanching, reactive hyperemia (engorgement): structural damage to the capillary bed/microcirculation.

Cyclosporine and azathioprine

Immunosuppressant meds; given when lesion do not respond to other therapies. Use as short-term therapy (< 6 months). ADR: Nephrotoxicity occurs and increases risk of infections. Client education: Monitor BP throughout therapy. Med can cause hypertension.

Signs of External Hemorrhaging

Obvious. Observe dressings covering a wound for bloody drainage. Bleeding is excessive if dressing becomes saturated, and frequently blood drains from under the dressing and pools beneath the patient.

Epithelialization

Occurs along wound edges or as islands inside wound bed: pale pink resurfacing of wound (new skin) (epithelial cells line the surfaces of the body: 3 stage process to cover in epithelialization)

Treatment for Psoriasis

There is no cure for psoriasis. Treatment is aimed at decreasing the severity of the manifestations and decreasing the turnover rate of the epidermal cells. *Topical therapies*: corticosteroids, tar preparations, vitamin D analogs, vitamin A. *Systemic meds*: cytotoxic meds, biological agents, cyclosporine and azathioprine