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Med Surg II > Derm/Burns > Flashcards

Derm/Burns Flashcards

1
Q

Integumentary System Functions

A
  • protects the body from pathogen invasions
  • regulates temperature
  • senses environmental changes
  • maintains water balance
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2
Q

Epidermis

A
  • superficial/outer layer
  • melanocytes synthesize pigment (melanin)
  • melanin: pigment that protects
  • Keratin: protein that strengthens
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3
Q

Dermis

A
  • middle, deeper layer of skin “true skin”
  • rich blood supply
  • mast cells
  • macrophages
  • sweat glands
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4
Q

Hypodermis

A
  • SQ
  • lowest lying layer of connective tissue
  • connects dermis to muscle
  • contains macrophages, fibroblasts, fat cells, nerves, blood vessels, lymphatics, hair follicle roots, fine muscles
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5
Q

Sebaceous gland

A
  • produce sebum to moisturize and protect the skin

- greatest number on palms, hands, feet soles, forehead

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6
Q

Sweat glands

A

Eccrine glands: secrete through skin pores in response to the SNS. Greatest number on face, chest, and back
Apocrine glands: fewer in #, produce more sweat, ducts open into the hair follicles. Found in the axillae, scalp, face, and external genitalia.

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7
Q

Age related changes r/t skin

A

-decreased sensations of pain, vibration, cold, heat, pressure, and touch.
- increased risk of injury including falls, decubitus ulcers, burns, and hypothermia
-decreased elasticity, integrity, and moisture
-appears thin, pale and translucent
-epidermis thins even through the number of cell layers remains unchanged
-large pigmented spots (lentigos) may appear in sun-exposed areas
-changes in the connective tissue reduce the skin’s strength and elasticity
-dermis blood vessels become fragile, leading to bruising, cherry angiomas, and other similar conditions
sebaceous glands produce less sebum
-subcutaneous fat layer thins
-sweat glands produce less sweat
-repairs itself more slowly

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8
Q

Assessment of the skin

A
  • preparation of the patient: explain purpose, provide privacy and coverings
  • assessment questions
  • inspect entire body
  • wear gloves
  • assess any lesions; palpate and measure
  • note hair distribution
  • photographs may be used to document nature and extent of skin conditions and to document progress resulting from treatment. Photographs may also be used to track moles
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9
Q

Papule

A

elevated mass with circumscribed border <0.5 cm

EX: elevated nevi, warts, lichen planus

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10
Q

Nodule

A

elevated, palpable, firm, solid, circumscribed lesion that extends deeper into dermis than a papule; 0.5-2 cm
EX: squamous cell carcinoma, lipoma, poorly absorbed injections

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11
Q

Plaque

A

coalesced papules with flat top >0.5 cm

EX: psoriasis, actinic keratosis

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12
Q

Tumor

A

don’t always have sharp borders; >1-2 cm

EX: larger lipoma, carcinoma

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13
Q

Macule

A

Flat, nonpalpable skin color change (brown, white, tan, purple, red) with circumscribed border <1cm
EX: freckles, flat moles, petechial, rubella, port wine stains, ecchymosis, vitiligo

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14
Q

Patch

A

> 1cm; may have irregular border

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15
Q

Wheal

A

elevated irregular shaped area of cutaneous edema with varying size and color caused by movement of serous fluid into the dermis
EX: urticarial (hives), insect bites

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16
Q

Vesicle

A

Elevated, circumscribed, palpable mass containing serous fluid <0.5 cm
EX: herpes, chickenpox, poison ivy, 2nd degree burn blisters

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17
Q

Bulla

A

> 0.5 cm

EX: pemphigus, contact dermatitis, large burn blisters, poison ivy, bullous impetigo

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18
Q

Pustule

A

puss-filled vesicle or bulla

EX: acne, impetigo

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19
Q

Cyst

A

encapsulated fluid-filled or semisolid mass in the SQ tissue or dermis

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20
Q

Scales

A

-2ndary lesion
-flaky skin; dead epithelium; color varies (silver/white); texture varies (thick/fine)
EX: dandruff, psoriasis, dry skin, pityriasis rosea

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21
Q

Erosion

A

-2ndary lesion
-loss of superficial epidermis that doesn’t extend to the dermis; depressed, moist area
EX: ruptured vesicles, scratch marks

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22
Q

Ulcer

A

-2ndary lesion
-skin loss extending past the epidermis, necrotic tissue loss, bleeding and scarring possible
EX: pressure ulcer

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23
Q

Fissure

A

-2ndary lesion
-linear crack in the skin that may extend to dermis
EX: chapped lips, athlete’s foot

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24
Q

Crust

A

-2ndary lesion
- dried residue of serum, blood or pus on skin. large adherent crust is a scab
EX: impetigo, herpes, eczema

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25
Q

Telangiectasia

A

-2ndary lesion
-widely open (dilated) blood vessels in the outer layer of the skin
EX: spider veins

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26
Q

Lichenification

A

-2ndary lesion
-thickening/roughening of the skin or accentuated skin marks secondary to repeated rubbing, irritation or scratching.
EX: contact derm.

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27
Q

Keloid

A

-2ndary lesion
-hypertrophied scar tissue secondary to excessive collagen formation during healing. Elevated, irregular, red; greater incidence among AA
EX: ear piercing

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28
Q

Scar (cicatrix)

A

-2ndary lesion
-replacement connective tissue after injury
EX: surgical incision

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29
Q

Excoriation

A

-2ndary lesion
- abrading or wearing off the skin
EX: chafing

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30
Q

Atrophy

A

-2ndary lesion
-thin, dry transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; underlying vessels may be visible
EX: aged skin

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31
Q

Skin lesion configurations

A
  • linear
  • annular and arciform (circular or arcing)
  • zosteriform (linear along a nerve route)
  • grouped (cluster)
  • discrete (separate and distinct)
  • confluent (merged)
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32
Q

Which of these would be considered a primary macule skin lesion?

A

Port-wine stain

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33
Q

Hyperpigmentation

A

-can be a result of sun injury

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34
Q

Hypopigmentation

A

-can be caused by a fungal infection, eczema, or vitiligo

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35
Q

Pallor

A

anemia, shock, arterial insufficiency, albinism, vitiligo

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36
Q

Erythema

A

hyperemia, inflammation, fever, ETOH, blushing, polycythemia, carbon monoxide poisoning, venous stasis

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37
Q

Cyanosis

A

chronic heart and lung diseases, arterial desaturation, exposure to cold, anxiety

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38
Q

Jaundice

A

increased bilirubin, increased carotene, uremia

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39
Q

Pruritus

A

itching usually related to primary skin disease; essential pruritus = itching without a rash/lesion

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40
Q

Brown-tan

A

Addison’s, café au lait spots

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41
Q

Skin biopsy

A

obtains tissue for microscopic examination via scalpel or punch of nodules, plaques, blisters & other lesions to rule out malignancy and establish diagnosis

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42
Q

Immunofluorescence

A
  • direct detects autoantibodies on skin

- indirect detects specific antibodies in PT serum

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43
Q

Patch testing

A
  • allergy testing
  • weak + = redness, fine elevations or itching
  • moderate + = fine blisters, papules or severe itching
  • strong + = blisters, pain or ulcerations
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44
Q

skin scrapings

A
  • fungal testing; microscopic examination
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45
Q

Tzanck smear

A

Test used to examine cells from blistering skin conditions (herpes, varicella, pemphigus); stained and examined under microscope

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46
Q

Wood’s light examination

A

special lamp that produces long wave UV waves that appear dark purple. Examination takes place in a dark room where hyper/hypopigmentation is differentiated.
-lesions without any melanin increase in whiteness with the light

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47
Q

Care of patient with skin conditions

A
  • objectives of therapy are to prevent additional damage, prevent 2ndary infection, reverse inflammatory processes, and relieve symptoms
  • nursing care: administration of topical and systemic medications, wound care and dressings, and providing for patient hygiene
  • nursing care also needs to address educational, emotional, and psychosocial needs of the patient
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48
Q

Impetigo

A
  • superficial infection of the skin caused by staph, strep, or multiple bacteria
  • bullous impetigo is more deeply seated infection caused by S-aureus & present with large bullae that rupture
  • Body, hands, neck, and extremities most often affected
  • Contageous
  • R/T poor hygiene, malnutrition; often follows head lice, scabies, herpes, insect bites, poison ivy or eczema
  • Systemic antibiotic therapy or topical antibiotic therapy prescribed
  • seen mostly in kids
  • HONEY COLORED SERUM VESICLES!!!
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49
Q

Folliculitis, furuncles, and carbuncles:

A
  • Folliculitis is an infection of bacterial or fungal origin in hair follicles (shaving bumps)
  • Only tx is to avoid shaving or use lotions
  • Furuncles are boils in an acute inflammation deep in a hair follicle that spreads into the surrounding dermis. Often appear as a small, red, raised, painful pimple. Tenderness eventually leads to a yellow or black center with a point.
  • Carbuncles are abscesses of the skin and SQ tissue that represent an extension of a furuncle that has invaded several follicles and is large and deeply seated. Usually caused by staph, most commonly seen on the neck and buttocks.
  • Furuncles and carbuncles are most likely in PTs with systemic diseases such as those on immunosuppressive therapy or with DM.
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50
Q

Herpes Zoster

A
  • viral infection
  • shingles
  • unilateral
  • an infection caused by varicella-zoster viruses
  • painful vesicular eruption along area of distribution of sensory nerves
  • pain, itching, tenderness, malaise and inflammation are unilateral
  • common complication is postherpetic neuralgia
  • antiviraly such as acyclovir (Zovirax), valacyclovir (Valtrex) or famciclovir (Famvir) are started within 24 hours of initial eruption.
  • systemic corticosteroids may be prescribed for PTs older than 50 to reduce neuralgia risk.
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51
Q

Herpes simplex

A
  • orolabial (fever blisters / cold sores)
  • genital (type 2)
  • tingling or burning may precede vesicles by 24 hours
  • triggers: sunlight, stress, illness
  • onset may be accompanied y fever, lymphadenopathy and malaise
52
Q

Fungal infections

A
  • Tinea (ringworm)
53
Q

Tinea pedis

A
  • athlete’s foot
  • soak feet in vinegar and water solution
  • griseofulvin or terbinafine (Lamisil) daily for 3 months
54
Q

Tinea coporis

A

-body; itchy clusters; infected pet may be source; topical antifungals or griseofulvin or terbinafine (Lamisil)

55
Q

Tinea capitis

A

-head; common in children; oval scaling patches with papules or pustules; griseofulvin for 6 weeks; shampoo hair 2-3x with Nizoral or selenium sulfide shampoo

56
Q

Tinea cruris

A
  • jock itch
  • small red scaling patches that form circular elevated plaques; itchy; topical antifungal creams or griseofulvin or terbinafine (Lamisil)
57
Q

Tinea unguium

A
  • toenails; nails thicken and crumble easily; itraconazole (Sporanox) in pulses of 1 week/month for 3 months
  • Onychomycosis
58
Q

Folliculitis

A
  • infection of the hair follicle
  • cause: staph aureus
  • Proliferates around the opening of follicle followed by distribution into the follicle
  • pustluse with surrounding erythema
59
Q

Furuncles

A
  • boils
  • inflammation of the hair follicles
  • may develop after folliculitis
  • Cause: S. aureus
  • deep, firm, red, painful nodule
60
Q

Carbuncles

A
  • abscess-extension of furuncle

- back of neck, upper back, lateral thighs

61
Q

Fungal infections (Table from textbook)

A
  • tinea thrive on keratin
  • superficial fungal infection
  • typically grow in warm, most places (shower)
  • typically manifests as a circular, red rash accompanied by pruritus and burning
62
Q

Patient Education r/t bacterial infections

A
  • impetigo is contagious and may spread to other parts of the body or to other persons
  • antibiotics, hygiene, skin and lesion care
  • don’t share towels, combs, and so on
  • bathe daily with antibacterial soap
  • furuncles, boils, or pimples should never be squeezed
63
Q

Patient education r/t viral infections

A
  • herpes zoster: instruction regarding prescribed antiviral medications, lesion care, dressings, and hand hygiene
  • herpes simplex: instruction regarding prescribed antiviral medications and prophylactic medication use, instruction regarding spread of herpes, and measures to reduce contagion of partner or of neonates born to mothers with genital herpes
64
Q

Patient education r/t fungal infections

A
  • instruction regarding medications, use of oral and topical agents, shampoos
  • hygiene: use clean towels and washcloths q day
  • do not share hygiene items
  • keep skin folds and feet dry
  • wear clean, cry, cotton clothing, including underwear and socks; avoid synthetic underwear, tight-fitting garments, wet bathing suits, and plastic shoes
  • avoid excessive heat and humidity
  • hair loss associated with tinea capitis is temporary
65
Q

Parasitic skin infections

A

-pediculosis (lice): pediculosis capitis, pediculosis corporis (body), pubis (genitals)

66
Q

Scabies

A
  • itch mite
  • sarcoptes scabei: infestation by itch mite
  • substandard hygienic conditions
67
Q

Patient education r/t Pediculosis capitis

A
  • may infest anyone and are not a sign of uncleanliness
  • use of shampoo (lindane - last resort (Kwell) or pyrethrin (RID)), NiX.
  • lindane may have toxic effects and must be used only as directed NEUROTOXIC effects- no longer 1st line
  • wash hot water > 130 degrees or dry clean
68
Q

Patient education r/t pediculosis corporis and pubis

A
  • poor hygiene and those living in close quarters
  • pediuclosis pubis spread chiefly by sexual contact
  • bath in soap and water
  • check for coexisting STDs
69
Q

Patient education r/t scabies

A
  • mite frequently involves fingers and hands
  • contact may spread infection
  • HCW wear gloves
  • warm, soapy bath; allow skin to cool; and apply prescription scabicide lindane, crotamiton, or 5% permethrin (med of choice) to entire body, not including the face or scalp. Leave on for 12 to 24 hours. Wash after- repeat in 1 week.
70
Q

Psoriasis

A
  • a chronic, noninfectious autoimmune inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate
  • improves and recurs; a lifelong condition
  • may be aggravated by stress, trauma, seasonal and hormonal changes
  • CM: scaly, thick. silvery, elevated lesions, usually on the scalp, elbows, or knees
71
Q

Psoriasis managment

A
  • PT education
  • measures to prevent skin injury: avoid picking or scratching
  • prevent skin dryness: use of emollients, avoid excessive washing, use warm (not hot) water, pat dry
  • use of the therapeutic relationship for support and to aid coping
  • medications: topical, systemic, phototherapy, baths to remove scales and medications.
  • Biologics (Humera), topical steroids, Coal tar, medicated shampoos, phototherapy
  • Caution with plastics - don’t smoke with plastic wrappings
72
Q

Pemphigus

A
  • group of skin diseases with bullae (blisters) of various sizes, on skin & mucus membranes
  • types: pemphigus vulgaris, bullous pemphigoid, dermatitis herpetiformis
  • autoimmune-IgG mediated; blisters from antigen-antibody reaction on the skin
  • Jewish-Mediterranean descent
  • may be associated with captopril, PCN, w/ myasthenia gravis
  • Medical tx: high dose steroids & immunosuppressant
73
Q

Blistering disease

A
  • assessment: appearance of the skin
  • oral lesions, painful, bleeding, large eroded areas, crusting, oozing. Sloughing and blistering of uninvolved skin w/ pressure or gentle rubbing (Nikolsky’s sign)
  • monitor vs frequently and assess for s/s of infection
  • pain, pruritus, and discomfort
  • coping of the patient with condition
  • note impact of the disease on life and interactions
  • complications: infection/sepsis, fluid volume deficit and electrolyte imbalance
74
Q

Interventions for blistering diseases

A
  • oral hygiene
  • avoid commercial mouthwashes
  • keep lips moist with lip balm, petroleum or lanolin
  • cool mist humidified air
  • cool, wet dressing or baths; hygiene measures
  • apply powder (nonirritating-cornstarch) liberally to keep skin from adhering to sheets
  • monitor for and prevent hypothermia
  • skin care may be similar to that of the PT with extensive burns
  • measures to prevent 2ndary infections
  • encourage adequate fluid and nutritional intake
75
Q

Safety r/t blistering diseases

A
  • infection is the leading cause of death r/t blistering disease
  • meticulous assessment is important
  • s/s of infection: local & systemic
  • minor changes may need to be explored b/c steroids can mask the typical s/s of infection
76
Q

Toxic Epidermal Necrolysis

A
  • Steven-Johnsons Syndrome
  • high mortality rate: fatal
  • rxn to medications: sulfonamides, NSAIDs, antiseizure, allopurinol
  • CM: conjunctival burning & itching, skin tenderness, fever, cough, sore throat, malaise, myalgia, erythema of skin & mucous membranes, bulla & epidermis sheds, erosion formation
  • management: discontinue causative agent, F&E balance, prevent sepsis & hypothermia, prevent ophthalmic complications, pain management, reduce anxiety, burn center
  • Complications: sepsis, MODS, conjunctival retraction, scars, and corneal lesions (visual impairment)
77
Q

Skin cancer

A
  • Basal cell carcinoma: most common type; located in epidermis
  • squamous cell carcinoma: epidermal keratinocyte; prognosis depends on presence of metastasis
  • malignant melanoma
  • Kaposi sarcoma
  • frequently r/t sun exposure
  • incidence is increasing
  • prevention involves protection from excessive sun exposure
78
Q

Care of the patient with Melanoma

A

Assessment: inspect skin carefully, ask specific questions about pruritus, tenderness, pain, changes in moles, or new pigmented lesions, assess knowledge level and risk factors, assess coping and anxiety, skin cancer inspection
-New pigment lesions

79
Q

ABCDs of moles

A

Asymmetry
Irregular BORDER
Variegated COLOR
DIAMETER < 6mm

80
Q

Management of patients with burn injuries

A
  • 450,000 buns per year; 14% die (4000)
  • most burns occur in the home
  • young children and older adults are at high risk for burn injuries
81
Q

Goals related to burns

A
  • Prevention education
  • role of ETOH and cigs., water temp 120F, hair appliances.
  • fire extinguishers in the home
  • institution of lifesaving measures for the severely burned person
  • prevention of disability and disfigurement through early specialized and individualized care
  • rehabilitation through reconstructive surgery and rehabilitation programs
82
Q

1st degree burn

A
  • superficial: epidermis layer only
  • burned tissue does not separate from the underlying dermis
  • Negative Nikolsky’s sign: rubbed skin doesn’t slough off
83
Q

2nd degree with superficial partial thickness

A
  • destruction of epidermis and some dermis

- blisters quickly, often the most painful

84
Q

3rd degree

A
  • full thickness
  • destruction of all skin layers and SQ tissue. Pain receptors are destroyed - pain may or may not be present
  • severity of this burn is often deceiving to PTs because they may have no pain in the injury area
85
Q

4th degree

A
  • full-thickness & deeper tissue
  • destruction of epidermis, dermis, underlying SQ tissue, tendons, muscles, and bone.
  • Pain absent
  • skin function-absent
  • black, charred appearance
86
Q

Staging a 1st degree burn

A

-destruction of dermis only

Example: Sunburn

87
Q

Staging of superficial partial-thickness burn (2nd degree)

A
  • destruction of epidermis and dermis

- pale and minimal exudate

88
Q

Staging of full-thickness burn (3rd degree)

A

-destruction of epidermis, dermis, and SQ layer

89
Q

Factors to consider in Determining burn depth

A
  • how the injury occurred
  • causative agent
  • temperature of agent
  • duration of contact with the agent
  • thickness of the skin
90
Q

TBSA

A

total body surface area

91
Q

Rule of 9s

A
  • most commonly used
  • arm 9%
  • leg 18%
  • head 9%
  • anterior chest 18%
  • posterior chest 18%
  • groin 1%
92
Q

Lund and Broder method

A
  • method for estimating TBSA of a person
  • takes into account age of the PT and various anatomic parts
  • evaluate patient initially and at 72 hours
93
Q

Palmer method

A
  • method for estimating TBSA of a person

- size of PTs hand, including the fingers is around 1% of that patient’s TBSA

94
Q

Zones of burn injury

A
  • Coagulation: no homogenous necrosis in center then viable tissue towards the periphery
  • Stasis: injured cells but may remain viable, still with decreased blood flow becomes necrotic in 24-48 hours
  • Hyperemia: minimal injury-may recover over time
95
Q

Physiologic changes r/t burns

A
  • Burns less than 25% TBSA produce primarily a local response
  • Burns more than 25% may produce a LOCAL & SYSTEMIC response and are considered major burns
  • Systemic response includes release of cytokines and other mediators into systemic circulation
  • fluid shifts and shock result in tissue hypoperfusion and organ hypofunction
96
Q

Effects of major burn injury

A
  • F&E shifts
  • Cardiovascular effects
  • Pulmonary injury: upper airway, inhalation below the glottis, carbon monoxide poisoning, restrictive defects
  • Renal and GI alterations
  • Immunologic alterations
  • Effect on thermoregulation
97
Q

3 phases of burn injury

A
  • Emergent or resuscitative phase: onset of injury to completion of fluid resuscitation; time required to resolve the immediate life threatening problems from the burn
  • Acute or intermediate phase: from beginning of diuresis to wound closure; wound is covered by tissue at this time
  • Rehabilitation phase: from wound closure to return to optimal physical and psychosocial adjustment. Most burns have healed, reconstructive and corrective procedures (overlaps acute phase). Goal: maximal independence & function
98
Q

Emergent or Resuscitative phase - ON THE SCENE CARE

A
  • Prevent injury to rescuer
  • Stop injury: extinguish flames remove from the source. Irrigate chemical burns. Electrical: shut off current & separate person from source. Cool the burn, cooling of the injured area within 1 minute helps minimize the depth of damage. Do not use ice-hypothermia and vasoconstriction
  • ABCs: airway, breathing, circulation
  • Start O2 and large-bore IVs
  • Remove restrictive objects and cover the wound with dry clean cloth.
  • do assessment surveying all body systems and obtain a hx of the incident and pertinent patient history
  • Note: treat patient with falls and electric as for potential cervical spine injury
  • patient is transported to ED
  • ABC-in the ED
  • Fluid resuscitation is begun-starting point is time of injury not time of arrival
  • Foley catheter is inserted for I&Os.
  • patient with burns exceeding 20 to 25% should have an NG tube inserted and placed to suction (paralytic ileus & opioids)
  • Patient is stabilized and condition is continually monitored
  • patients with electrical burns should have ECG
  • address pain; only IV medication should be administered
  • psychosocial consideration and emotional support should be given to patient and family.
99
Q

Use of the nursing process in the care of the patient in the emergent phase of burn care - Diagnosis

A
  • impaired gas exchange: provide humidified O2, assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor PT for signs of hypoxemia. Monitor arterial blood gas values, pulse O2, Carboxyhemoglobin levels, prepare to assist with intubation and escharotomies, monitor vented patient’s closely.
  • Ineffective airway clearance
  • fluid volume deficit
  • hypothermia
  • acute pain
  • anxiety
100
Q

Acute respiratory failure

A

-Dyspnea, striodor, O2 sats, CXR

101
Q

Distributive shock

A
  • monitor decrease urine output 30-50 mL or 75-100 mL for electrical burns
  • Assess edema with fluid shifts, adjust fluids
  • Goal: 0.5 mL/kg/hr
  • maintain blood pressure of greater than 100 mm Hg
  • maintain serum sodium at near-normal levels
102
Q

Acute renal failure

A
  • urine output, BUN, Cr, assess urine for hemoglobin or myoglobin-predisposes PT to increased risk of kidney failure.
  • Give fluids to flush renal tubules
103
Q

Compartment syndrome

A
  • pulses, compare affected with unaffected sides, elevate the extremity, take off bp cuff each time
  • prepare to assist with escharotomies
104
Q

Paralytic ileus

A
  • bowel sounds
  • NG suction
  • Monitor abdominal distention
105
Q

Curling’s ulcer

A
  • monitor NG suction for blood and stools

- H2 blockers/ PPIs

106
Q

F&E Shifts - Emergent phase

A
  • generalized dehydration
  • reduced blood volume and hemoconcentration
  • decreased urine output
  • trauma causes release of potassium into extracellular fluid: hyperkalemia
  • sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia
  • metabolic acidosis
107
Q

Acute or intermediate Phase care

A
  • begins 48 to 72 hours after injury
  • continue assessment and maintain respiratory and circulatory support
  • prevention of infection, wound care, pain management, and nutritional support are priorities in this stage
108
Q

Use of the nursing process in the care of the patient in the acute phase of burn care- diagnosis

A
  • excessive fluid volume
  • risk for infection: hydrotherapy equipment.
  • imbalanced nutrition
  • acute pain
  • impaired physical mobility
  • ineffective coping
  • interrupted family processes
  • deficient knowledge
109
Q

F&E Shifts - Acute Phase

A
  • fluid reenters the vascular space from the interstitial space
  • Hemodilutions: decreased hematocrit
  • increased urinary output
  • sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia
  • potassium shifts from extracellular fluid into cells: potential hypokalemia
  • metabolic acidosis
110
Q

Use of the nursing process in the care of the patient in the acute phase of burn care - collaborative problems and potential complications

A
  • HF and pulmonary edema
  • sepsis
  • acute respiratory failure
  • visceral damage (electrical burns)
111
Q

Rehabilitation Phase Care

A
  • rehab is begun as early as possible in the emergent phase and extends for a long period after the injury
  • focus is on wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality of life, both personally and socially.
  • the patient may need reconstructive surgery to improve function and appearance
  • vocational counseling and support groups may assist the patient.
112
Q

Pain management r/t burns

A
  • burn pain has been described as one of the most severe forms of acute pain
  • pain accompanies care and tx such as wound cleaning and dressing changes
  • Types of burn pain: background or resting, procedural, breakthrough
  • Analgesics: IV use during emergent and acute phases, morphine, fentanyl, others.
  • role of anxiety in pain
  • effect of sleep deprivation on pain
  • nonpharmacologic measures
113
Q

Nutritional support

A
  • burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs r/t stress response, hypermetabolism, and requirement for wound healing.
  • goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization
  • Nutritonal support is based on PT preborn status and % of TBSA burned
  • Enteral route is preferred
  • breathing must be assessed and patent airway established immediately during the initial minutes of emergency burn care
114
Q

Fluid resuscitation formula

A

2mL x PT weight in kg x TBSA% = 24 hour total

Give 1/2 amount over 1st 8 hrs and the 2nd 1/2 of 24 hour total over next 16 hours.

115
Q

Silver sulfadizine 1%

A
  • silvadene
  • most bactericidal agent
  • minimal penetration of eschar
  • leukopenia
116
Q

Mafenide acetate 5% to 10%

A
  • Sulfamylon
  • Broad spectrum
  • electrical burns; penetrates thick eschar
117
Q

Silver nitrate 0.5%

A
  • bacteriostatic and fungicidal
  • does not penetrate eschar
  • monitor serum Na and K
  • high ability to stain
118
Q

Acticoat

A
  • broad spectrum, some yeasts and molds

- delivers a uniform, antimicrobial concentration of sliver to the burn wound

119
Q

Burn wound cleaning

A
  • bathing: maintain water and room temp

- hydrotherapy

120
Q

Burn wound debridement

A
  • removal of dead/contaminated tissue
  • natural
  • mechanical (bedside with scalpel)
  • chemical (topical agents)
  • surgical
121
Q

burn wound dressing

A
  • make sure they are not impeding the circulation

- check pulses frequently

122
Q

Burn wound dressing changes

A
  • premedicate the patient
  • inspect the area and document thoroughly
  • wound grafting
  • decreases risk of infection, prevent further loss of protein, F&E.
  • promotes heat loss
  • promotes earlier functional ability and reduces wound contractures
123
Q

Hypovolemic Shock

A
  • increased capillary permeability - usually persists for 24 hours after burn injury
  • causes massive fluid, electrolyte, and protein loss into the interstitium from the circulating blood volume.
  • this leads to hypovolemic shock and edema
  • decreased cardiac output and contractility = impaired perfusion of vital organs
  • increased blood viscosity due to loss of fluid = predisposes to increased clotting
  • decreased perfusion of the viscera = decreased gut barrier function = translocation of bacteria and endotoxemia with sepsis
124
Q

Hypermetabolic response to burn

A
  • tachycardia, hypercapnia, and body wasting develop
  • increased O2 consumption, increased glucose use, protein and fat wating
  • tissue hypoxia produces lactic acidosis
  • peaks 7-17 days post injury
125
Q

Sepsis

A
  • due to actual burn injuries or due to complications
  • phagocytosis is impired and cellular and humoral immunity is decreased
  • pneumonia, UTI
  • loss of 1st line of defense (skin) and loss of normal flora
  • inability to deliver inflammation and immune mediators to sites.

Med Surg II (4 decks)

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