Exam 1 Flashcards
What are some ways to advocate health promotion
Avoiding environmental hazards
Adequate hygiene and good nutrition
Skin self-examination
Periodic professional exams for areas difficult to see
What is the NUMBER ONE environmental hazard when it comes to skin
The sun
What are the two types of ultraviolet rays
UVA
UVB
What does exposure to UVA cause
tanning
What does exposure to UVB cause
sunburn
What are some other factors to consider as environmental factors to sun exposure
High altitude
Being in snow
Tanning booths
What kind of ultraviolet is the worst type
UVB
True or false: Broad spectrum sunscreen covers both rays
True
When should you avoid the sun
Anywhere from 10 AM- 2 PM
How can you be safe when going outside
Wearing protective layers
How often should you be reapplying suncreen?
Every 2 hours and reapply after swimming
What are other environmental hazards when it comes to skin care
Irritants and allergens Radiation Sleep Exercise Hygiene Nutrition Medications
What are some major classes of medications that cause photosensitivity
Antibiotics
Antidepressants
Psych
Some risk factors for skin cancer
Having fair skin Blonde or red hair, blue eyes Outdoor sunbathing Living near the equator (more exposed to the sun) high altitudes History of skin cancer
Actinic keratosis is a type of ____
Nonmelanoma skin cancer
In what population is actinic keratosis common
In older white adults
What is the number one way to get a clear diagnosis when it comes to skin diagnosis
BIOPSY
Actinic Keratosis is also known as
Solar keratosis
What is the first line of treatment for actinic keratosis
Nonsurgical procedures and biopsy
What is the most common precancerous skin lesion
Actinic keratosis
What kind of topical medication can be used to treat actinic keratosis and what does it do
Topical 5-FU
Will erode lesions over several weeks
What is some nursing education for the topical medication 5-FU
Teach patients that pain and burning is normal to feel when on this medication
Seborrheic keratoses is what kind of skin problem
Benign
When does seborrheic keratoses usually occur
After age 40
What are the clinical manifestations of seborrheic keratoses
Well defined shape
Appearance of being stuck on
Increase in pigmentation with time
Can look like melanoma
Because seborrheic keratoses can look like melanoma what is important to diagnose
BIOPSY
How is seborrheic keratoses removed
Cryosurgery
Curettage
What is the most common type of skin cancer
Basal cell carcinoma
What is the the least deadly skin cancer
Basal cell carcinoma
BCC (basal cell carcinoma) occurs most commonly in what population
Middle-aged to older adults
You have an open sure that doesn’t heal, a shiny bump or nodule, or small pink growth or scar like that were not there before
Basal cell carcinoma
What are the types of basal cell carcinoma
Nodular BCC Superficial BCC Pigmented BCC Morphoeic BCC Basosquamous BCC
What are some nonmelanoma skin cancers
Actinic keratosis
BCC
Squamous cell carcinoma
Squamous cell carcinoma (SCC) occurs where on the skin
The first layer
True or false SCC is aggressive and has potential to metastasize
True
What are the main risk for SCC
Sun exposure
Immunosuppression after organ transplantation
What contributes to the formation of SCC on the mouth and lips
Pipe, cigar, and cigarette smoking
SCC will appear in places where
You’ve had sun exposure
Moles that look suspicious but are not cancer
Atypical/dysplastic nevus
Can be precursor for melanoma
atypical nevus
What are some causes of malignant melanoma
Environmental factors
Genetics factors
What is the main cause of melanoma
UV radiation from the sun
What are some risk factors for malignant melanoma
Red or blonde hair Light-colored eyes Fair skin that freckles Chronic sun exposure Family history
True or false: people who are more likely to get sunburned are more likely to get melanoma
True
What is the ABCD rule
Asymmetry Border irregularity Color change Diameter > 6mm Evolving in appearance
If the mole looks different than the other moles then you should be ____
Suspicious
Treatment for malignant melanoma is determined by what
Site of original tumor
Stage of the cancer
Patients age and general health
What is the initial treatment for malignant melanoma
Surgical excision
What additional (adjuvant) therapy is often required for malignant melanoma
Chemo but mostly used for advanced disease
What happens when melanoma gets into the lymph
It can metastasize everywhere in the body
remove layers of skin slowly and looking at them under microscope until we don’t see anymore cancerous tissue; done as outpatient procedure so don’t need to be NPO; they are very effective because they don’t have to go in multiple times; teach patient that ice is their best friend because they will have a lot of inflammation
Moh’s procedure
Moh’s procedure can be indicated for what
Malignant melanoma
You want to catch melanoma early because survival rate for later stages is so low. We try to catch it early by doing what
Educating patients on what to look for
Cross section of the skin is taken and the depth of the tumor is determined; thickness of the lesion determines the treatment
Breslow measurement
Medical term for hives
They are raised and generalized
Urticaria
Chronic hive infection
Chronically exposed to something
Stays around for a long period of time
Allergic contact dermatitis
Patch testing can help determine possible causative agents of
Contact dermatitis
What do you treat contact dermatitis with
Steroids and moisture we NEVER want to give antibiotics for this
Another name for atopic dermatitis
Eczema
What do you treat atopic dermatitis with
Steroids and moisture
Type 4 delayed hypersensitivity response
Sensitization occurs after one or more exposures
Red papules and plaques
Contact dermatitis
Type 1 hypersensitivity response
Genetically influenced, chronic, relapsing disease
Exaggerated by a skin response to environmental allergens
Atopic dermatitis
Topical immunomodulator used to treat atopic dermatitis
Elidel which helps with inflammation
What patient teaching should you given when giving Elidel
Burns on application
Corticosteroids can be given to patients with atopic dermatitis but can cause what
Skin thinning leaving patient at more risk for skin breakdown
When is Stevens Johnson Syndrome (SJS) usually seen
With IV medication
Acts and looks like a burn
Stevens Johnson Syndrome
Severe and life threatening conditions that will cause skin to fall off
Stevens Johnson Syndrome and toxic epidermal necrolysis (TEN)
Stevens Johnson syndrome is a systematic and _____ response
Heightened
It is important to maintain what in Stevens Johnson
A patent airway
Allergic skin reaction involving less than 10% of total body surface area
SJS
Allergic skin reaction involving more than 30% of total body surface area
TEN (toxic epidermal necrolysis)
Phototherapy
Treats many skin problems including psoriasis
What are some side effects of phototherapy
Nausea
Itching
Erythema
What are the best candidates for radiation therapy to treat BCC and SCC
- patients with lesions in challenging locations such as the ear, nose, scalp, neck and shin
- those how have trouble with wound healing
- those with comorbidities who can’t have surgery
This form of treatment can help make measurable, repeatable, consistent zones of tissue damage with a decreased risk for scarring
Laser technology
Some medications used as drug therapy to treat dermatologic problems
Steroids Corticosteroids Antihistamines Topical Fluorouracil Immunomodulators
What are diagnostic and surgical therapies for dermatologic problems
Skin scraping Curettage Punch biopsy Cryosurgery Excision-Moh's procedure
The removal and scooping away of tissue using an instrument called a curette
Curettage
Punch biopsy
Procedure used to obtain tissue sample or to remove small lesions
A punch is rotated into the skin and a small cylinder of skin is removed
Punch biopsy
The use of subfreezing temp. to destroy epidermal lesions
Cryosurgery
___ is an option if the lesion involves the dermis
Excision
Microscopically controlled removal of a skin cancer by removing tissue sections in this horizontal layers
Moh’s procedure
Use this for superficial skin problems that involves inflammation, itching, and infection
Wet compresses
This is an appropriate intervention for treatment of large areas of the body
Baths
How do you apply topical medications
Topical medications are applied with gloves, in the direction of the hair, and in a thin even layer
Pruritus
Medical term for itching
How to control pruritus
- Break the itch/scratch cycle
- Cool environment causes vasoconstriction decreasing itching
- Hydration, wet compresses, moisturizers
- Topical meds
Why do we want a patient with pruritus to avoid anything that causes vasodilation like heat and rubbing
Vasodilation will cause increased blood flow resulting in inflammation and more itching
How can you prevent the spread of skin infections
Always wear gloves when working with open would
Proper handwashing
How to prevent secondary skin infections
Hand washing and proper dressing changes
How can you help patients dealing why chronic dermatologic problems and their psychological effects
- Reinforce to the patient to follow the prescribed regimen
- Refer patient to support groups
- Camouflage like makeup but also consider product ingredients when recommending them
Occur when there is injury to the skin or other tissues of the body caused by heat, chemicals, electrical current, or radiation
Burns
Burns are a ____ issue because everything is affected by burns
Systemic
True or false” Most burn accidents are preventable
True
What are the types of burns
Thermal Chemical Inhalation Electrical Radiation Cold
Caused by flame, flash, scald, or contact with hot objects
Thermal burn
What is the most common type of burn injury
Thermal burn
The severity of injury from burn depends on what
- Temperature of burning agent
- Duration of contact time
Result of contact with acids, alkalis, and organic compounds
Chemical burns
___ burns can be more difficult to manage because they cause protein hydrolysis and melting
Alkali
Where can alkali be found
Found in cement
Oven and drain cleaners
Heavy metal cleaners
True or false chemicals can be very hard to get off so they can cause a burn to be more severe because it is on pt. for longer
True
Caused by breathing noxious chemicals or hot air which can damage the respiratory tract
Smoke inhalation injuries
____ ____ ____ are major predictor of mortality in burn victims
Smoke inhalation injuries
Rapid initial and ongoing assessment is critical in smoke inhalation injuries because
airway can be compromised and pulmonary edema can happen quickly
What are the three types of smoke inhalation injuries
- Upper airway injury
- Lower airway injury
- metabolic asphyxiation
This happens when you breathe in carbon monoxide or hydrogen cyanide
Metabolic asphyxiation
Impaired oxygen delivery to tissues occurs in what type of burn injury
Metabolic asphyxiation
Impaired oxygen to tissue in metabolic asphyxiation results in what
- Hypoxia
- Elevated carboxyhemoglobin levels
- Death when carboxyhemoglobin levels are >20%
Metabolic asphyxiation can still occur in the absence of a ___
Burn injury
What will be the first indicator that the patient is not getting enough oxygen
Decreased LOC
How to determine if patient has metabolic asphyxiation
Test carboxyhemoglobin levels
Results from injury to the mouth, oropharynx, and/or larynx
Upper airway injury
This injury is caused by thermal burns of the inhalation of hot air, stream or smoke
Upper airway injury
Mucosal burns of oropharynx and larynx are manifested by ___, ___, and ___.
Redness
Blistering
Edema
What would be a good indication that the person has an airway injury
Soot around their mouth or nose
In what type of airway injury will swelling be massive and have a rapid onset
Upper airway injury
Important to remember from upper airway injury
Eschar and edema may compromise breathing
Edema from facial and neck burns can be lethal
Internal pressure from edema may narrow airway
True or false patients with an upper airway injury may need to be trached very early on bc of the concerns for their airway
True
Injury to the trachea, bronchioles and alveoli and usually caused by breathing in toxic chemicals or smoke
Lower airway injury
In a lower airway injury tissue damage is related to ___ of exposure to toxic fumes or smoke
Duration
In a lower airway injury pulmonary edema may not appear until when
12-48 hours after burn
Once pulmonary edema appears in a lower airway injury it may manifest as what
Acute respiratory distress syndrome (ARDS)
Why does pulmonary edema take longer to manifest in a lower airway injury
Because it is deeper in the body
With a lower airway injury what are we more concerned with
Breathing rather than airway
What do want to asses for in a lower airway injury
Facial burns Singed nasal hair Hoarseness Painful swallowing Darkened oral and nasal membranes Carbonaceous sputum: coughing up black and soot History of being burned in enclosed space Clothing burns around neck and chest
These burns results from intense heat generated from an electric current
Electrical burns
These kinds of burns may not be externally apparent
Electrical burns
With a patient with electrical burns it is VITAL that _____ monitoring is done
Cardiac
Electrical burns leave patients at risk for what
Dysrhythmias
These kinds of burns can result in direct damage to nerves and vessels causing tissue anoxia and death
Electrical burns
The severity of an injury from electrical burns depends on what
- amount of voltage
- tissue resistance
- current pathways
- surface area
- length of time current flow was sustained
Electrical burns will leave more damage when there is more tissue ____
Resistance
Electricity that only went one way
Monophasic electricity
Electricity that came in and bounced around
Biphasic electricity
True or false:
Current that passes through vital organs produces more life-threatening sequelae than current that passes through other tissues
True
Before when shocking patients and there would be oxygen present it could lead to patient
Catching on fire
What kind of burn injury leaves patients at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria
Electrical injury
What causes myoglobin to be released
When there is massive muscle damage it is released in circulation where it travels to kidneys and cause blockage
What causes hemoglobin to be released in an electrical injury
Massive blood vessel damage causes RBC to be broken down, hgb then travels to kidney where it can cause blockage
What causes an acute tubular necrosis and acute kidney injury in an electrical injury
Myoglobin and hemoglobin travel to the kidneys can block renal tubules
Exposure to extremely low temps or prolonged exposure to low temps leads to what kind of burns
Cold burns
Cold burns start with ___, ___, then ___
Swelling, blistering, dry necrosis
Burns used to be defined by degrees which used to be what
First, second, and third degree
ABA now classifies burns according to what
Depth of skin destruction
How does the ABA now classify burns
Partial thickness burn
Full thickness burn
Involves the epidermis
First degree burn
Sunburn
Superficial partial thickness burn
Involves the dermis
Second degree burn
Deep partial thickness burn
Involves all skin elements, nerve endings, fat, muscle, bone
Third and fourth degree burn
Full thickness burn
With this degree of burn there is only damage to the epidermis with no blisters but there is pain, mild swelling, and erythema
Superficial partial thickness burns
With this degree of burn there is damage to the epidermis with fluid filled blisters, severe pain, mild to moderate edema
Deep partial thickness burn
What is important to educate the patient when it comes to blisters from burns
DO NOT POP THEM
With this degree of burn there is damage to all skin layers and beyond; it’s dry, waxy, leathery, insensitive to pain
Full thickness burn
Why is there no pain with fourth degree burn or full thickness burn
Because the nerve endings have been damaged
What degree is the most painful kind of burn because the nerves are irritated
Deep partial thickness
What are the two common tools for determining the total body surface area when it comes to burns
Lund-Browder chart
Rule of nines
Out of the two common tools to determine total BSA which one is more accurate
Lund-Browder
What is the rule of nines
The front of the head: 4.5% Back of the head: 4.5% The upper chest: 9% Upper back: 9% The abdomen: 9% Lower back: 9% Genitals: 1% Hand with finger 1% Front part of arm: 4.5% Back part of each arm: 4.5% Each anterior part of the leg 9% Each posterior part of the leg: 9%
The severity of burn injury is determined by the __ of burn wound
Location
Burns to what locations are more severe because they can interfere result in respiratory obstruction from edema and eschar
Face
Neck
Chest
Back
Burns to what locations are of concerns because they make self-care difficult and may jeopardize future function
Hands, feet, joints and eyes
Burns to what locations can leave pt. at risk for infection as the skin is very thin and underlying cartilage may be exposed
Ears, nose, buttocks, perineum
Circumferential burns of extremities can cause ___ problems
Circulation
Patients with burns can develop ____ syndrome
Compartment
The greatest initial threat to a patient with a major burn is ____ _____
Hypovolemic shock
What is third spacing
Fluid shifts from the vascular system or blood vessels and into the cells
Third spacing causes blood volume to increase or decrease
Decrease
Lower blood volume causes blood to become
Thicker
This is the time needed to resolve the immediate, life-threatening problems resulting from a burn injury
Emergent (resuscitative) phase
The emergent phase lasts up to ___ hours
72
What are the main concerns in the emergent phase of a burn injury
Hypovolemic shock
Edema
When does the emergent phase end
When fluid mobilization and diuresis begins
Fluid and electrolyte shifts can begin as early as ___ minutes postburn
20
In fluid and electrolyte shifts in burn patients does colloidal osmotic pressure increase or decrease
Decrease
In third spacing how does fluid shift
Out of the vascular space into interstitial spaces
What are examples of third spacing in burn injury
Exudate and blisters, and edema in unburned areas
Why does colloidal pressure decrease in burn injury
Because of the progressive loss of protein from the vascular space
What is normal urine output by the hour
30-50 mL/hr
In a severely burned patients insensible losses increase or decrease
Increase
Signs of hypovolemic shock
Decreased BP
Increased heart rate
Is hematocrit increased or decreased in burn victims
Increased
Thrombosis in the capillaries of burned tissue causes there to be less
RBCs
A potassium shift develops because injured cells and hemolyzed RBSs release ___ into circulation
Potassium
What electrolyte moves into the interstitial spaces and stays there until edema formation ends
Sodium
How do you correct or prevent hypovolemic shock in burn injuries
Fluid resuscitation
Given them massive amount of fluids and increase the fluid in intravascular space
How to determine how much fluid to give burn patients
Parkland (Baxter) Formula
What is the Baxter formula
4 ml of LR per kg/%TSBA for 1st 24 hours
½ of total in 1st 8 hours
¼ of total in 2nd 8 hours
¼ of total in 3rd 8 hours
Example of Baxter formula:
You have a 70 kg pt. with a 50% TBSA burn
4 ml x 70 kg x 50 (TSBA)= 14,000 ml in 24 hr
1/2 of total in first hour= 7000 ml
1/4 of total in second 8 hr= 3500 ml
1/4 of third 8 hr= 3500 ml
Before doing fluid resuscitation we need to intubate or check their ___
Airway
You’ll need 2 large bore IV placed for patients with burns that are what % of TBSA
15% or more
For burns greater than 20% we’ll need to insert a
Central line
This kind of line is placed if frequent ABGs or invasive BP is needed
Arterial line
Two main parameters need to be monitored during fluid therapy
Urine output
Cardiac output
Urine output goals for burn patients should be
1 mL/kg/hr
What are cardiac output goals for burn patients
MAP >65
HR <120
SBP >90
What are some immunologic changes when burn injury occurs
Skin barrier is destroyed
Bone marrow depression occurs
Circulating levels of immune globulins are decreased
Defects occur in function of WBCs
Why are circulating levels of immune globulins decreased in burn injuries
Because of all that fluid that moved into the cells
Defects occurring in the function of WBCs in burn injuries can cause what
Patient to be at greater risk for infection
What re your first priorities during the emergent care of burn injuries
SAFETY AND DECONTAMINATION
- live electrical wires
- fire
- chemical spills
- smoke
Airway management of the burn injury patient involves early
Endotracheal intubation
Escharotomies of the chest may be needed for what for the burn patient
To relieve respiratory distress with circumferential full thickness burns of the neck and chest
What is an escharotomy
Surgical incision done to remove pressure from eschar
Fiberoptic bronchoscopy is done to assess the lower
Airway after injury if smoke inhalation is suspected and needed for intubation
Treatment of inhalation injury may require giving __% humidified oxygen
100
True or false: It is important to place the burn pt. in high fowlers, provide suctioning and chest physiotherapy.
True
What kind of medications may be indicated for burn pts. to treat severe bronchospasm
Bronchodilators
What are some clinical manifestations during he emergent phase of burn victims
Shock Pain Blisters Paralytic ileus Shivering Altered mental status
Why does paralytic ileus happen with burn injuries
SNS response of all blood diverted away from GI system
What is paralytic ileus
Condition where the motor activity of the bowel is impaired
What causes shivering with a burn injury
Shivering is a response from the heat loss
What causes the altered mental status in a burn patient
Hypoxia causes this
What are complications from burn injuries
- Circumferential burns can lead to escharotomy
- Dehydration and shock
- Acute tubular necrosis ATN may need dialysis
- Infection
When does the acute phase of a burn injury begin
Begins with mobilization of extracellular fluid and subsequent diuresis
When does the acute phase of a burn injury end
When Partial thickness wounds are healed or
Full thickness burns are covered by skin grafts
Bowel sounds return during what phase of the burn injury
During the acute phase
During this phase the necrotic tissue begins to slough
Granulation tissue forms
Acute phase
During acute phase partial thickness burns heal from wound edges and dermal bed known as ____ intention
Secondary
During acute phase full thickness burns have to have ____ removed and ___ ____ applied
Eschar
Skin grafts
What kind of nutritional therapy will burn pts. in acute phase need
High protein and calories
Is it important to give pt. pain medication prior to or after debridement
Prior
When is the best time for exercise for a burn pt. in the acute phase
During dressing changes when they’ve been medicated for pain
What are the major therapeutic interventions in the acute phase of a burn injjury
- wound care
- excision and grafting
- pain management
- PT and OT
- nutritional therapy
What are the goals of wound care
- to prevent infection by cleansing and debriding the area of necrotic tissue
- promote wound re-epithelialization and/or successful skin grafting
What does surgical debridement mean
Removal of the necrotic tissue
Burn patients will be on ____ isolations
Reversed isolations similar to neutropenic precautions
When open burn wounds are exposed, staff should wear PPE such as
Disposable hats
masks
gowns
gloves
___ gloves need to be used to apply antimicrobial ointment and sterile dressings
Sterile
It is important to use custom fitted splints in areas that bend so that we maintain join ___
Function
What is an allograft
Skin graft taken from burn patients own skin usually the thigh to place somewhere else
What is a homograft
Skin graft taken from donor cadavers
This type of graft is used with newer biosynthetic options
Homograft
What are some analgesics and sedatives used in drug therapy for burn patients
Morphine Hydromorphone (Dilaudid) Haloperidol (Haldol) Lorazepam (Ativan) Midazolam
Why do we give burn pts. sedatives
It can help them not have flashbacks to what caused the burns and also because they can develop anxiety from dressing changes
Why are burn pts. given tetanus shot
As prophylactic treatment for anaerobic burn would contamination
Why are antibiotics not used for burns
Because the eschar has no blood supply so little antibiotic is delivered to the wound and could also lead to resistant bacteria
Silver sulfadiazine and Mafenide acetate are both used for what
They are topical agents used as antimicrobial agents
Antimicrobial agents do what
Penetrate the eschar and inhibit bacterial invasion
___ therapy is started when the diagnosis of sepsis is made or when some other source of infection is identified
Antibiotic
What is the leading cause of death in pt. with major burns and may lead to multiple organ dysfunction syndrome
Sepsis
Why are burn pts. given low molecular heparin
Because they are at risk for VTE but only given if not contraindicated
Burn pts. with high bleeding risk are given what for VTE prophylaxis
Compression devices or stockings until heparin until bleeding risk decreased and heparin can be started
___ takes priority once fluid replacement needs have been addressed
Nutrition
Early and aggressive ____ support within hours of burn injury
Decreases complications and mortality
Optimizes burn wound healing
Minimizes negative effects of hypermetabolism and catabolism
Nutritional
Because the burn injury destroys the body’s first line of defense the wound is colonized by the ___ own flora
Patient’s
Burn patients have WBCs with a functional deficit leaving patient
Immunosuppressed
___ can cause partial thickness burns to convert to full-thickness wounds
Infection
These s/s mean what hypothermia or hyperthermia increased HR and RR decreased BP decreased urine output
Indicate infection
Causative organisms of sepsis are usually gram ___ bacteria
Negative
What do you want to do if sepsis is suspected
Get cultures from all sources
Get lactate level
This lab shows lactic acid levels and if normal shows that there is sufficient oxygen at the cellular level and that any s/s are not due to lactic acidosis
Lactate level
___ level identifies sepsis
Lactate
What are some neurological complications in the acute phase
- Disorientation
- Combative
- Hallucinations
- Frequent nightmare-like episodes
