Download Ch 42 Integumentary

Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 42
Care of Patients with Integumentary Disorders
and Burns
Copyright © 2017, Elsevier Inc. All rights reserved.
Theory Objectives




Describe the etiology of dermatitis.
Plan psychosocial interventions for the
patient who has psoriasis.
Compare and contrast the treatment of fungal
skin or nail disorders to the treatment of
bacterial skin disorders.
List the main nursing care points for patients
with herpes virus infections.
Copyright © 2017, Elsevier Inc. All rights reserved.
2
Theory Objectives (Cont.)




Discuss the types of acne and their treatment.
Compare the characteristics of the various
types of skin cancer.
Analyze the important points of caring for an
immobile patient to prevent pressure ulcers.
Prepare care plan interventions for each
stage of a pressure ulcer.
Copyright © 2017, Elsevier Inc. All rights reserved.
3
Theory Objectives (Cont.)




Summarize important assessment points for
the patient who has sustained a burn.
Evaluate the nurse’s role in emergency burn
care.
Evaluate the psychosocial needs and
interventions for burn patients.
Describe the process of rehabilitation for the
patient with a major burn.
Copyright © 2017, Elsevier Inc. All rights reserved.
4
Clinical Practice Objectives





Teach a family about care for the patient and
home when scabies is present.
Assess the skin of family members for signs of
skin cancer.
Provide care for a patient with stage III or stage
IV pressure ulcer.
Apply Standard Precautions and sterile
techniques for the care of a burn.
Visit a burn intensive care unit and observe the
wound care of a patient who is in acute stage of
a major burn.
Copyright © 2017, Elsevier Inc. All rights reserved.
5
Inflammatory Infections to the Skin


Skin disease result from – bacteria, virus,
fungus or parasites
May or may not be contagious
6
Dermatitis

Not contagious unless there
is a secondary infection in
the lesions

Contact dermatitis – cell
mediated immunity= allergen
bound to protein carrier forms
antigen then T cells become
sensitized to the antigen.
Cosmetics, soaps, latex,
poison ivy, chemical irritants
cause such a reaction
Copyright © 2017, Elsevier Inc. All rights reserved.
7
Atopic dermatitis – common with
infants/children
Complex activation process – more
prevalent in families
8
9

Stasis dermatitis – occurs in legs as a result
of venous statis and edema –varicosities,
phlebitis and vascular trauma. Develop
lesions which may become ulcerated
10
Seborrheic dermatitis – common on
the scalp, lesions appear scaly white
or yellow plaques
11
Dermatitis


Diagnosis and treatment –
visual inspection, hx looking
for possible causative
substances
Nursing management –
avoidance of substance,
applying ointments correctly
and good skin care. If the
patient has pruritus – avoid
getting hot, bathe in tepid
water and don’t puncture
vesicles.
12
Contact Isolation Requirements Box
42-1 page 971
13
Audience Response Question 1
In managing dermatitis, the nurse provides
which instruction(s)? (Select all that apply.)
1.
2.
3.
4.
5.
Avoid the irritant or allergen.
Provide adequate skin lubrication.
Wash skin frequently with germicidal soaps.
Maintain skin moisture.
Apply steroid-based preparations.
Copyright © 2017, Elsevier Inc. All rights reserved.
14
Acne


Disorder of the skin characterized by papules and
pustules over face, back and shoulders
Two types – acne rosacea and acne vulgaris
Occupational acne- caused by prolonged contact
with oils and tars – chemicals in the environment or
cosmetics
Copyright © 2017, Elsevier Inc. All rights reserved.
15
Acne

Acne Rosacea – ages 30 to 50 years old.
Erythema, papules, pustules and
telangiectases. Occurs on face and over
bridge of the nose
16
Acne vulgaris

More common. Begins in early puberty has a
hereditary component, increased androgen
levels, hormonal fluctuations. It is NOT
contagious and diet does NOT affect acne.
17
18
Treatment for acne


Acne rosacea – avoid triggers for flareups –
topical ABTs – Metronidazole (MetroGel) and
retinoids
Acne vulgaris – topical medications Retin-A,
Benzoyl peroxide, Azelaic acid (Azelex) and
Veltin Gel. ABT are sometimes prescribed to
inhibit growth of bacteria
19
Acne- Nursing Managment


Patient and families need support for
physiologic and psychosocial support
Wash face with mild soap, scrubbing skin not
recommended, if hair is oily wash frequently
and keep off the face, squeezing outbreaks
may press sebum into the clogged duct
increasing chances of inflammation and
possibly spreading infection
20
Accutane – side effects




Accutane – effective in control of
cystic acne found to have many
severe side effects.
Accutane discontinued in 2009, but
still available in generic form
Should only be used for severe
cystic acne-side effects include
organ damage and mental problems
Almost all patients experienced
some side effect to this drug
21
Audience Response Question 2
A teenager asks the nurse at the dermatologist’s
office, “What is acne vulgaris?” Which
statement(s) would be true? (Select all that apply.)
1.
2.
3.
4.
5.
“Accumulations of sebum in occluded sebaceous
glands.”
“It is caused by increased androgens and fluctuating
premenstrual hormones.”
“Application of heavy creams and heat exposure
contribute to the development of acne.”
“Alcohol, caffeine-containing foods, spicy foods,
sunlight, and emotional stress cause flare-ups.”
“These lesions are not a sign of uncleanliness.”
Copyright © 2017, Elsevier Inc. All rights reserved.
22
Psoriasis





Not contagious
Chronic
Affects 2% of U.S. population, family
component
Inflammed, edematous skin lesions covered
with scales
Scales are a result of abnormal rapid rate of
proliferation of skin cells. Appear on elbows,
fingernails, knees and base of the spine. May
also appear on palms and soles of feetaffected patient’s ability to perform ADLs.
Copyright © 2017, Elsevier Inc. All rights reserved.
23
Psoriasis Dx and Tx





Dx determined by physical exam to rule out
other skin disorders
Steroids creams triamcinolone acetonide
(Kenalog)
UV light slows down rate cells are produced
Calcipotriene (Dovonex) Vit D analog cream
regulates skin cell production
Coal tar products with UV radiation PUVA
therapy
24
Psoriasis Lesion on the Hand
From Ignatavicius DD, Workman ML: Medical-surgical nursing:
patient-centered collaborative care, ed. 6, Philadelphia, 2010,
Saunders.
Copyright © 2017, Elsevier Inc. All rights reserved.
25
Nursing Management



Skin kept moist – humidifiers used to keep
moisture in environment
Lotions and creams applied three min after
showering
Caution against abrasions – may lead to
additional growth of psoriatic plaques
26
Stevens-Johnson Syndrome

Signs and symptoms –allergic reaction with
skin manifestations within 14 days of starting
a drug therapy


Anticonvulsants carbamazepine (Tegretol) and
phenytoin (Dilantin), the antimalarial sulfadoxine–
pyrimethamine (Fansidar), and the antibiotic
Sulfamethoxazole- sulfamethoxazole (Bactrim,
Septra)
OTC medications can also cause SJS
Copyright © 2017, Elsevier Inc. All rights reserved.
27
Stevens-Johnson Syndrome




Nursing interventions….
Discontinue the drug.
Provide supportive care – fluids & nutrition
Provide wound care – similar to that of a
burn.
28
Bacterial Infections of the Skin



Cellulitis – infection of dermis and
subcutaneous tissue – generally caused by
Staphylococcus. Cellulitis appears as a
swollen, red area of skin that feels hot and
tender. It can spread rapidly to other parts of
the body.
Skin on lower legs is most commonly affected
it may also affect tissues underlying your skin
and can spread to your lymph nodes and
bloodstream.
If untreated, can be life-threatening.
Copyright © 2017, Elsevier Inc. All rights reserved.
29
Cellulitis
30
Cellulitis Treatment

Risk factors for developing cellulitis include
intravenous drug use, chronic skin conditions
that weaken the skin surface, fungal skin
infections and lowered immunity.
31
Bacterial infections of the skin



Furuncles (boils) – inflammation of hair
follicles usually staphylococcus aureus
Carbuncles – collection of infected hair
follicles
Tx: warm compresses, incision and drainage
antibiotics for recurrent episodes
32
Viral Infections of the Skin
Herpes Simplex



Herpes simplex virus type 1 (HSV-1) lesions
are primarily nongenital most commonly
causes cold sores.
Herpes simplex virus type 2 (HSV-2) is most
often associated with genital herpes. This is
a STD virus. Can be transmitted without
lesions visible.
Contagion is possible up to 5 days after
appearance of the lesion
Copyright © 2017, Elsevier Inc. All rights reserved.
33
Herpes simplex
34
Herpes Simplex (Cont.)
Copyright © 2017, Elsevier Inc. All rights reserved.
35
Herpes Simplex (Cont.)


Etiology and pathophysiology – virus infects and
imbeds the nerve ganglion on the site of the
lesion, can be reactivated by stress, light, skin
irritation, fatigue or stress
Diagnosis



History and physical examination
Treatment – topical or oral acyclovir (Zovirax),
famciclovir (Famvir) or valacyclovir (Valtrex)
Nursing management

Good personal hygiene helpful to prevent spread of
the virus
Copyright © 2017, Elsevier Inc. All rights reserved.
36
Herpes Zoster (Shingles) chickenpox
virus

Etiology and pathophysiology




Dormant in peripheral nerve ganglia and can be
reactivated by trauma, malignancy, or local radiation
High risk: immunocompromised individuals (HIV/AIDs,
cancer patients)
Vaccine available Zostavax is 50% effective for 6 years
Signs and symptoms



Low grade temp
Aching or discomfort along the nerve pathway
3 to 5 days after onset, vesicles found on trunk
following nerve pathway
Copyright © 2017, Elsevier Inc. All rights reserved.
37
Herpes Zoster (Shingles) (Cont.)
Copyright © 2017, Elsevier Inc. All rights reserved.
38
Diagnosis and Treatment




History and physical examination
Symptomatic treatment – very painful for
several days or weeks after the skin lesions
are healed. Topic analgesic 5x a day.
Antibiotics against secondary bacterial
infection – acyclovir (Zovirax), famciclovir
(Famvir) valacyclovir (Valtrex)
Systemic corticosteroids to reduce
inflammation
Copyright © 2017, Elsevier Inc. All rights reserved.
39
Herpes Zoster - Precautions




Visitors, health care workers should NOT be
in contact with patient if they have never had
the virus
Pregnant health care workers should not care
for a patient with the virus – can harm fetus
Initiate isolation procedures based on
symptoms rather than wait for diagnosis
Transmission precautions until all blisters are
crusted
40
Fungal Infections of the Skin

Fungal infections are called mycoses
41
Fungal Infections of the Skin – 2 types



1 -Fungi that are truly
pathogenic to humans
2 -Opportunistic infections
can cause infection to a
patient with an altered
immune system
Tinea pedis (athlete’s foot or
dermatophytosis), tinea
cruris (jock itch), tinea of the
scalp (ringworm), and tinea
barbae (barber’s itch)
Copyright © 2017, Elsevier Inc. All rights reserved.
42
ringworm
43
Oral thrush
Moniliasis (thrush) fungal infection attacks
mucous membranes of the mouth, rectum
and vagina (candidiasis)
44
Fungal Infections (Cont.)



Older adults and onychomycosis – develop
fungal infections of the fingernails or toenails
Topical ointment for a year or oral antifungal
medications itraconazole and terbinafine
(highly toxic to liver) for several months. Or
combination of both. Recurrence is very high
Laser treatments are also becoming more
frequently used
Copyright © 2017, Elsevier Inc. All rights reserved.
45
Fungal Infections (Cont.)

Diagnosis



Microscopic examination of skin scrapings that
have been treated with potassium hydroxide
(KOH) solution
Preventing recurrent fungal infection – see
page 977 “Patient teaching”
Complementary and alternative treatment of
nail fungus - tea tree oil topical daily takes
weeks to months to work. Vicks Vapor Rub.
Copyright © 2017, Elsevier Inc. All rights reserved.
46
Onychomycosis (Nail Fungus)
Copyright © 2017, Elsevier Inc. All rights reserved.
47
Tinea Pedis Athlete’s Foot


Excessive warm/moist public places –
swimming pools, spas, showers –
Trichophyton mentagrophytes are the usual
infectious agents
Skin between the toes becomes inflamed and
develops cracks that become painful fissures.
Intense itching is common
Copyright © 2017, Elsevier Inc. All rights reserved.
48
49
Tinea Pedis



Dx: physical exam
Tx: keep area dry, clean, exposed to air and
sunlight. Burow solution soaks. Topical
antifungals: ketoconazole (Nizoral),
econazole (Spectazole) Naftifine (Naftin) plus
oral medications itraconzole (Sporanox)
terbinafine (Lamisil)
Nursing mgt: daily regular application of
ointment, use own towel, clean shower area
to prevent transmission
50
Parasitic Infections of the Skin Pediculosis and Scabies

Etiology and pathophysiology





Schools, nursing homes, dormitories –
parasites can infest anyone
Signs and symptoms


The head louse, Pediculus humanus capitis
The body louse, Pediculus humanus corporis
The pubic or crab louse, Phthirus pubis
Severe itching leading to excoriation
Diagnosis

Body inspection and examination of skin scraping
Copyright © 2017, Elsevier Inc. All rights reserved.
51
lice
52
Parasitic Infections


All types are acquired by contact with infested
people or their clothing, bed linen and
bedding.
Pets are also carriers of lice and scabies
mites
53
Treatment and Nursing Management
Parasitic Infections




Prescription drugs cremes, lotions or
shampoo..permethrin (Nix, Elimite) pyrethrins
(RID) and malathion (Ovide) toxic to liver,
must monitor with liver function tests.
Fine-toothed (nit) comb to remove eggs
Contact isolation is recommended, laundering
in hot water
Preventing reinfestation
Copyright © 2017, Elsevier Inc. All rights reserved.
54
Audience Response Question 3
The nurse who observes evidence of severe
itching on the scalp of a school-aged girl with
pediculosis should give which important
instruction(s)? (Select all that apply.)
1.
2.
3.
4.
5.
“Machine wash clothes and bedding using the
coldest cycle.”
“Share combs and hair brushes.”
“Soak all combs and brushes in very hot water for
more than 5 minutes.”
“Seal items that cannot be washed in air-expelled
plastic bags for 14 days.”
“Instruct all family members about the infestation
and ways to prevent reinfestation.”
Copyright © 2017, Elsevier Inc. All rights reserved.
55
Noninfectious Disorders of the Skin Skin Cancer

Chronic exposure to
ionizing radiation,
petrochemicals, vinyl
chloride, or other irritants

Alteration in the ozone
layer of the earth’s
atmosphere that allows
more UV radiation to
reach the earth’s surface
Copyright © 2017, Elsevier Inc. All rights reserved.
56
Three Major Types of Skin Cancer –
page 980 Table 42-1





Basal cell carcinoma
Squamous cell carcinoma
Superficial spreading melanoma (SSM)
Nodular malignant melanoma (NMM)
Lentigo maligna melanoma (LMM)
Copyright © 2017, Elsevier Inc. All rights reserved.
57
Skin Cancer (Cont.)

Diagnosis

Examination, biopsy, and pathology
• Basal cell carcinoma—removal and radiation therapy
• Squamous cell carcinoma and actinic keratoses—
removal and radiation therapy


Malignant melanoma – requires surgery for
removal of tumor and excision of adjacent tissues
Genetic predisposition, solar radiation, and steroid
hormone influence
Copyright © 2017, Elsevier Inc. All rights reserved.
58
Malignant Melanoma

Major kinds of malignant melanoma



Superficial spreading –horizontal growth for years
Nodular – prognosis less favorable
Lentigo maligna melanoma – rare, on hand, on the
face and under fingernails. Tends to metastasize,
prognosis poor
Copyright © 2017, Elsevier Inc. All rights reserved.
59
Treatment




Surgical removal of the tumor and excision of
adjacent tissues and nearby lymphatic
structures
Chemotherapy – for migrating tumor cells
Radiation therapy – not indicated for
malignant melanoma unless there is
extensive metastasis
Early detection and removal of cancerous
tissue is key
Copyright © 2017, Elsevier Inc. All rights reserved.
60
Basal Cell Carcinoma
Copyright © 2017, Elsevier Inc. All rights reserved.
61
Squamous Cell Carcinoma
Copyright © 2017, Elsevier Inc. All rights reserved.
62
Nursing Management



Report different skin lesions and prompt
medical attention
Patient education and reassurance – if
treated in early stages cure is successful.
Those with skin cancer history should be
checked at least once a year
Local community resources, support groups
Copyright © 2017, Elsevier Inc. All rights reserved.
63
Melanoma
Copyright © 2017, Elsevier Inc. All rights reserved.
64
Malignant Melanoma Drug Therapy




Interferon alfa-2b
Ipilimunab (Yervoy)
Vemurafenib (Zelboraf)
Boosts the immune system to help fight
cancer. These treatments are made of
substances produced by the body or similar
substances produced in a laboratory. Side
effects of these treatments are similar to
those of the flu, including chills, fatigue, fever,
headache and muscle aches.
65
Non-Infectious Disorders of the Skin Pressure Ulcers

Risk factors


Confinement, immobility, incontinence,
malnutrition, decreased level of consciousness or
confusion, obesity, diabetes mellitus, dehydration,
edema, excessive sweating, and extreme age
Prevention

Pressure relief, positioning, padding, use of
pressure relief devices, adequate nutrition, and
excellent skin care
Copyright © 2017, Elsevier Inc. All rights reserved.
66
Non-Infectious Disorders of the Skin Pressure Ulcers
 Cells
die very quickly without
adequate blood supply.
67
Pressure Ulcers (Cont.) page 983


Braden scale system or the Norton system
National Pressure Ulcer Advisory Panel
(NPUAP) staging system for classification





Suspected deep tissue injury
Stage I
Stage II
Stage III
Unstageable
Copyright © 2017, Elsevier Inc. All rights reserved.
68
Pressure ulcers
69
Stage I Pressure Ulcer
Area of intact skin that is reddened, deep pink or mottled that does
not blanch
Copyright © 2017, Elsevier Inc. All rights reserved.
70
Stage II Pressure Ulcer
Partial thickness skin loss involving the
epidermis or dermis. Skin appears blistered
surrounded by reddened tissue
Copyright © 2017, Elsevier Inc. All rights reserved.
71
Stage III Pressure Ulcer
Crater-like ulcer. Bacterial infection is almost always
present accounts for continued erosion and drainage
Copyright © 2017, Elsevier Inc. All rights reserved.
72
Stage IV Pressure Ulcer
Deep ulceration and necrosis involving deeper underlying muscle
and possibly bone tissue. Ulcer can be dry, black and covered with
necrotic tissue
Copyright © 2017, Elsevier Inc. All rights reserved.
73
Unstagable wound
Full thickness wounds with eschar and/or
tissue that obscures depth of wound
74
Treatment and Nursing Interventions
for Pressure Ulcers

Débridement
Dead tissue is removed so that the underlying tissue
may heal. Surgical – forceps and scissors, mechanically - whirpool baths,
wet-to-dry sale dressings and chemically with dextranomer beads sprinkled
over the wound or other chemical products. Sufficient analgesia must be
provided to the patient process can be painful
Copyright © 2017, Elsevier Inc. All rights reserved.
75
Treatment and Nursing Interventions
for Pressure Ulcers



Cleansing and dressing – irrigated with
normal saline to reach undermined areas and
tunnels. Dressing include hydrogel,
alginates, biologics, etc. Pressure must be
kept off the wound for it to heal
Other treatment methods – wound vac for
chronic ulcers, hyperbaric oxygen therapy
Documentation – measured once a week,
note exudate from wound, methods of
treatment noted in chart
76
Color of Purulent Exudate and
Probable Pathogen
COLOR EXUDATE
MAY INDICATE
Beige with a fishy odor
Proteus
Brown with a fecal odor
Bacteroides
Creamy yellow
Staphylococcus
Green-blue with a fruity odor
Pseudomonas
Copyright © 2017, Elsevier Inc. All rights reserved.
77
Documentation and Pressure Ulcer
Scale for Healing (PUSH) tool

Documentation and Pressure Ulcer Scale for
Healing (PUSH) tool
78
Non-Infectious Disorders to the Skin
Burns

Etiology and pathophysiology





Injuries to the skin from extreme heat, hot liquids,
electrical agents, strong chemicals, radiation,
inhaling smoke or fumes
Electrical burns- damage tissue deep within the
body, cardiac monitoring initiated
Chemical burns- accidents at home, work.
Radiation – from therapeutic radiation treatment
Burns cause an acute inflammatory response
should be considered life threatening until
thoroughly assessed
Copyright © 2017, Elsevier Inc. All rights reserved.
79
Non-Infectious Disorders to the Skin
Burns Dangers





Hyperkalemia- potassium is released from
damaged cells
Hyponatremia – potassium shifts leads to
metabolic acidosis.
Hypovolemia – low blood pressure and
possible hypovolemic shock
Increased viscosity of the blood –blood flow
slows causing tissue hypoxia
Curling ulcer – decreased perfusion affects
gastric mucosa – this ulcer may develop
within 24 hours
80
Non-Infectious Disorders to the Skin
Burns

Signs and symptoms – slight reddening to full
loss of tissue to bone with black, charred
areas. Blisters may form.
81
Classification of Burns



“Rule of nines” percentage of total body
surface that has been burned and depth of
the burn for adults
Lund-Browder classification or the Berkow
chart – compute the depth of the burn, extent
of injury according to age
Current method – evaluate depth of burns
based on the layers of skin that have been
damaged - Partial- and full-thickness wounds
Copyright © 2017, Elsevier Inc. All rights reserved.
82
Tissues Involved in Burns of
Various Depths - page 987
Copyright © 2017, Elsevier Inc. All rights reserved.
83
Partial-Thickness Burn Injury
Epidermal appendages are not destroyed and wound will heal by
itself.
Copyright © 2017, Elsevier Inc. All rights reserved.
84
Full-Thickness Burn Injury
All layers of skin involved and destruction of epidermal
appendages. Requires grafting for wound to heal
Copyright © 2017, Elsevier Inc. All rights reserved.
85
Classification of Burn Depth – see table
42-3 page 968







Color
Edema
Pain
Blisters
Eschar
Healing time
Grafts required
Copyright © 2017, Elsevier Inc. All rights reserved.
86
First Aid for Minor Burns






Run cool water over the burn continuously for
10 to 15 minutes.
Apply cool compresses if continuous water
flow is not available.
Do not apply ice, ice water, butter, or
ointments.
Do not pop blisters.
Cover loosely with a sterile gauze bandage.
Take ibuprofen or acetaminophen for pain.
Copyright © 2017, Elsevier Inc. All rights reserved.
87
Emergency Treatment of Burns





All burn patients are treated as trauma
patients
Establish and maintain airway 1st priority
Oxygen and pulse oximetry
Assessment for carbon monoxide inhalation –
check for mucous membranes for cherry red
color
Intravenous fluid therapy and more extensive
medical treatment. Transfer to burn center
according to guidelines
Copyright © 2017, Elsevier Inc. All rights reserved.
88
Emergent Phase of Burns – 24 to 48
hours (may last 3 days)



Tetanus toxoid IM injection
Respiratory support – upper airways may be
burned, swelling may occur. s/s respiratory
distress – increased RR, use of accessory
muscles, nasal flaring, restlessness and
confusion.
Burn patients observed for respiratory
problems: burns on face/neck, dark/black
sputum, burning sensation in throat or chest
and hx of burned in an enclosed space.
Copyright © 2017, Elsevier Inc. All rights reserved.
89
Emergent Phase of Burns – 24 to 48
hours (may last 3 days)




Fluid resuscitation and prevention of shock –
circulatory collapse. Replacement of lost
fluids and electrolytes and enhancement of
tissue perfusion. Parkland formula used see
page 989.
Unless fluids are replaced – cardiac output
will drop and shock may be fatal. Extreme
fluid deficit will cause acute renal failure.
Lab data checked frequently for status of
electrolytes
Pain management
90
Fluid Resuscitation and
Prevention of Shock

4 mL of Ringer’s lactate  % Burn  Weight in
kilograms




Half of the required fluid should be given within 8
hours of the time of the burn.
The second half is given over the next 16 hours.
Fluids are based on specific volume and
electrolyte imbalances and response to
treatment.
Calculated from the time of injury, not from
the time of arrival at the medical facility
Copyright © 2017, Elsevier Inc. All rights reserved.
91
Emergent Phase of Burns – 24 to 48
hours (may last 3 days)




Pain management – IV morphine or
hydromorphone hydrochloride (Dilaudid) at
high levels – 2 to 4 mg every 5 to 10 minutes.
Fentanyl with benzodiazepine prior to wound
care procedures
NSAIDs not used with grafting due to possibly
of stress ulcers
Gabapentin and methadone for chronic pain
92
Acute Phase of Burns


Acute phase – from time that fluids mobilize
and burned area is covered by grafts or
healed. Management of pain and anxiety,
promote nutrition and rehabilitation
Prevention of infection – any signs of infection
should be reported immediately, IV antibiotics
specific to bacteria in the wound are given
with topical ABT applied to wound.
Copyright © 2017, Elsevier Inc. All rights reserved.
93
Acute Phase of Burns

Wound treatment – six principles see page
990. Cleansed using sterile technique.
Remove excess exudate, topical ointment like
Bacitracin usually applied every 8 hours.
Silver sulfadiazine used for burns, does not
penetrate eschar.
94
Burn Wound treatment





Escharotomy – eschar impairs healing and is a
source of infection. 1 week after burn eschar is
removal with skin grafting. Eschar can also
constrict tissue perfusion – escharotomy
performed with incision into subq tissue.
Débridement – removal of eschar done in the OR
Grafting
Complications
Rehabilitation phase
95
Escharotomy of the Lower Extremity
From Lewis SL, Heitkemper MM, Dirksen SR, et al: Medicalsurgical nursing: assessment and management of clinical problems,
ed. 9, St. Louis, 2011, Mosby.
Copyright © 2017, Elsevier Inc. All rights reserved.
96
Signs of Infection






Strong odor
Color change to dark red or brown
Redness around edges extending to
nonburned skin
Texture change
Exudate and purulent drainage
Sloughing of graft
Copyright © 2017, Elsevier Inc. All rights reserved.
97
Nursing Care of Burns







Manage pain.
Prevent infection.
Manage itch.
Nutritional support
Psychosocial support
Patient-family education
Community care
Copyright © 2017, Elsevier Inc. All rights reserved.
98