Sensory/Integumentary System (Exam One) Flashcards
Describe repair wound healing.
The healing of connective tissue that is already present
What is primary intention wound repair?
The initial closure of a wound by some type of suture
The edges of a wound are approximated with what type of wound repair?
Primary intention
List the types of wound repair.
- Primary
- Secondary
- Tertiary
Describe secondary intention wound repair.
Wound is cleaned and then left open to heal itself from the inside out
What type of wounds require secondary intention repair?
- Wounds with wide irregular margins
- Wounds with extensive tissue loss
- Wounds with infection
The edges of a wound cannot be approximated in what type of wound repair?
Secondary intention
Describe tertiary intention wound repair.
Wounds that are initially left open and later closed by some type of suture
Why is closure of a wound delayed with tertiary intention wound repair?
Due to contamination or infection
What must be done before a tertiary intention wound can be closed with sutures?
Control the infection
What two factors determine how well a wound will heal?
- Shape
- Location
List factors of the body that make wounds harder to heal.
- Body parts that have constant pressure
- Moving body parts
What is dehiscence?
Wounds that split or burst open
What is the primary risk factor for wound dehiscence?
Obesity
List the complications of wound healing.
- Steroid use
- Diabetes
- Poor nutrition
- Smoking
- Age
- Anemia
What is hypertrophic scarring?
Overabundance of scar tissue following the same size and direction of the wound
What is keloid scarring?
Overabundance of scar tissue that is raised
What population is most at risk for keloid and hypertrophic scarring?
African Americans
What is the main difference between keloid scarring and hypertrophic scarring?
Keloid scars do not follow the same size and direction of the original wound
How should a wound bed appear?
- Moist
- Pink
What happens if the wound bed is dry?
Prevents the wound from granulizing and healing properly
Why are antibiotics not used with most wounds?
- Want to avoid killing good bacteria
- Superinfection may occur with overmedicating
What is the main building block of skin and promotes wound healing?
Protein
What hormone will delay wound healing?
Cortisol
The nurse should educate the patient to avoid being outside during what time?
10 AM to 2 PM
What environmental factor is the most damaging to the skin?
Sun
What type of ultraviolet rays are known for causing skin cancer?
UVB
List medications that cause photosensitivity.
- Antibiotic medication
- Psychiatric medication
What antibiotic is highly photosensitive?
Tetracycline
List risk factors for developing skin cancer.
- Fair skin
- Blonde/Red hair and blue eyes
- Outdoor sunbathing
- Tanning booths
- High altitudes
- History of skin cancer
In order to determine if a skin lesion is malignant or non-malignant, what must be done?
Biopsy
If a patient is prescribed topical 5FU, what education should the nurse provide?
Pain and burning sensations are common side effects of this medication
Which skin cancers are very common amongst older adults?
- Actinic keratosis
- Seborrheic keratosis
How is seborrheic keratosis differentiated from melanoma?
Biopsy
Squamous cells are which layer of skin?
Top layer
Basal cells are which layer of skin?
Middle layer
Where are melanocytes found?
Underneath the squamous and basal cell layers
Which type of skin cancer is the most common?
Basal cell carcinoma
Where does basal cell carcinoma most commonly occur?
Skin disruptions or scarring
Basal cell carcinoma is most commonly associated with what?
Repeated sun exposure
People with these conditions are most likely to develop squamous cell carcinoma?
Immunosuppressed/immunocompromised patients (i.e. transplant patients)
Squamous cell carcinoma may develop inside of the mouth due to what?
Smoking
Which non-melanoma skin cancer is most likely to metastasize?
Squamous cell carcinoma
Which individuals are most at risk for developing malignant melanoma?
- Genetically predisposed
- Fair skinned with blonde/red hair and blue eyes
Describe the ABCDE rule for identifying malignant skin neoplasms.
- Asymmetrical
- Border irregularity
- Color change
- Diameter >6 mm
- Evolving in appearance
What is the top priority intervention measure for preventing malignant melanoma?
Educating the patient
Describe a Moh’s procedure.
Layers of the skin are removed very slowly until no more cancer cells are visible under a microscope
What is the survival rate if malignant melanoma is discovered during Stage 3 or Stage 4?
10%
What is the survival rate if malignant melanoma is discovered during Stage 0?
100%
What tool is used to measure and stage skin cancer?
Breslow Measurement
What does the thickness of a lesion determine?
Prognosis
What happens if a patient with contact dermatitis is prescribed antibiotics?
Skin flora will be destroyed
Corticosteroids may cause what skin condition? What does this put patients at risk for?
- Thinning of the skin
- Skin breakdown
Describe Steven Johnson syndrome.
- Systemic inflammatory reaction that spreads over the entire body
- Blisters will form, burst, and skin will fall off
What is the main nursing priority for a patient with Steven Johnson syndrome?
Maintaining airway
What causes Steven Johnson syndrome?
Drug reaction
When is Red Man syndrome most likely to occur? Is this the same as Steven Johnson syndrome?
- When vancomycin is pushed too quickly
- No
How would the nurse treat swelling caused by a Moh’s procedure?
Ice
Burns are highly ________.
Systemic
What is the most common type of burn injury?
Thermal burns
What are the causative agents of thermal burns?
- Flame
- Flash
- Scald
- Contact with hot object
Chemical burns are typically caused by what type of solution?
Alkaline solutions
Why are alkaline chemical burns more difficult to manage?
Cause protein hydrolysis and melting
What is the universal solvent? Can this solvent be used on all chemical burns?
- Water
- No
Where should the nurse look for a list of safe solvents?
Medical Safety Data Sheet (MSDS)
What is the primary nursing priority for a patient with a smoke inhalation injury?
Maintaining airway
A patient with smoke inhalation injury will need what type of assessment?
Rapid initial and frequent, continuous assessments
List the three types of smoke inhalation injury.
- Upper airway injury
- Lower airway injury
- Metabolic asphyxiation
Describe metabolic asphyxiation.
Inhaled chemicals change the chemistry of the blood in the body impairing oxygen delivery to tissues
List the signs and symptoms of metabolic asphyxiation.
- LOC
- Mental status changes
- Hypoxia
Upper airway smoke inhalation injuries involve what structures?
- Mouth
- Oropharynx
- Larynx
List the signs and symptoms of an upper airway smoke inhalation injury.
- Redness
- Blistering
- Edema
- Soot around mouth and nose
Upper airway smoke inhalation injuries will cause what type of ABC problem?
Airway
Lower airway smoke inhalation injuries involve what structures?
- Trachea
- Bronchioles
- Alveoli
A lower airway smoke inhalation injury may manifest as what?
Acute Respiratory Distress Syndrome (ARDS)
Pulmonary edema may not appear until how long after a lower airway smoke inhalation injury?
12 to 48 hours
Lower airway smoke inhalation injuries will cause what type of ABC problem?
Breathing
What happens to the alveoli during a lower airway smoke inhalation injury?
Alveoli become too full of fluid to exchange oxygen
List the signs and symptoms of lower airway smoke inhalation injury.
- Facial burns
- Singed nasal hairs
- Hoarseness
- Painful swallowing
- Carbonaceous sputum
Swelling from an inhalation injury can lead to what?
Airway obstruction
Affected lung tissue from an inhalation injury can lead to what?
- Low gas exchange
- Hypoxia
- LOC changes
What is the priority nursing intervention for a patient who has electrical burns?
Cardiac monitor
Do electrical burns appear more internalized or externalized?
Internalized
Electrical burns are most likely to cause direct damage to what?
- Nerves
- Vessels
Are solid organs or hollow organs more likely to be damaged from an electrical burn? Why?
- Solid organs
- Electricity has more surface area to travel through
In regard to electrical burns, what type of electrical flow is most detrimental to the patient?
Biphasic
Electrical burns put patients at an increased risk for what clinical manifestations?
- Dysrhythmias
- Cardiac arrest
- Metabolic acidosis
- Myoglobinuria
- Anoxia
Myoglobinuria caused by electrical burns may result in what other acute conditions?
- Acute tubular necrosis
- Acute kidney injury
What areas of the body are most susceptible to cold burns?
- Fingers
- Toes
- Nose
How does the ABA classify burns?
Depth of skin destruction (burn)
Superficial partial-thickness burns involve what layer of the skin?
Epidermis
List an example of a superficial partial-thickness burn.
Sunburn
Deep partial-thickness burns involve what layer of the skin?
Dermis
Full-thickness burns involve what layer of the skin?
- All skin elements
- Nerve endings
- Fat
- Muscle
- Bone
Which type of burn is the most painful?
Deep partial-thickness burns
List the signs and symptoms of deep partial-thickness burns.
- Fluid-filled blisters
- Severe pain
- Mild/moderate edema
What type of education should the nurse provide to a patient with deep partial-thickness burns?
Do not pop the blisters
List the signs and symptoms of full-thickness burns.
- Dry
- Waxy
- Leathery
- Insensitive to pain
What tool is considered most accurate for determining total body surface area percentage?
Rule of Nines
Describe the Rule of Nines and the percentage of each body surface area.
See Slide 64 of Skin Disorders Powerpoint
How is the severity of a burn injury determined?
By location
If suffering from a burn injury, what locations on the body pose an increased risk for respiratory obstruction?
- Face
- Neck
- Chest
Which locations on the body would pose self-care difficulty if burned?
- Hands
- Feet
- Joints
- Eyes
If burned, which locations on the body are at an increased risk for infection?
- Ears
- Nose
- Buttocks
- Perineum
Circumferential burns of extremities can cause circulation problems ________ to the burn area.
Distal
If a patient has nerve damage to an extremity resulting from a burn, what other condition might they develop?
Compartment syndrome
Describe third spacing.
Movement of body fluid from inside the blood vessels to the interstitial space
What happens to the blood if third spacing occurs?
Becomes thicker
What is a patient as risk for if they have third spacing and thick blood?
- Blood clots due to poor perfusion
- Electrolyte imbalances
What will the body do as a reaction to burns?
- Swell
- Third spacing
Third spacing may appear as or cause what?
- Exudate
- Blisters
- Edema in unburned areas
What amount is considered a normal insensible loss?
30mL to 50mL
Insensible loss will __________ in a severely burned patient.
Increase
Describe vital sign changes in a patient with third spacing.
- Decreased blood pressure
- Increased heart rate
What is hemoconcentration?
Ratio of red blood cells are increased compared to the amount of plasma
What can hemoconcentration cause?
- High hematocrit
- Blood clots
What electrolyte shift will appear first in a burn patient?
Potassium
Why will potassium be the first electrolyte to shift in a burn patient?
Injured cells and hemolyzed red blood cells (RBCs) release potassium into circulation
How long will sodium remain in the interstitial spaces on a burn patient?
Until edema formation ends
What is done to prevent/correct hypovolemic shock in burn patients?
Fluid resuscitation
What tool is used to tell the nurse how much fluid to give during fluid resuscitation?
Parkland (Baxter) formula
Describe the Parkland (Baxter) formula and how much fluid to administer during fluid resuscitation.
-4mL x kg x %TBSA for first 24 hours
- 1/2 of total in first 8 hours
- 1/4 of total in second 8 hours
- 1/4 of total in third 8 hours
What must be secure before giving a patient fluid resuscitation?
Airway
A central line will be required in a burn patient if what percentage of the total body surface area is burned?
More than 20%
When would an arterial line be placed in a burn patient?
If frequent ABG’s or invasive blood pressure monitoring is needed
A nurse who is managing fluid needs on a burn patient should expect the minimum urine output to be what?
1mL/kg/hr
What vital signs are considered normal in a burn patient?
- MAP of >65
- HR <120
- SBP >90
A nurse who is managing fluid needs on a burn patient knows what about the relation of fluid input and output?
Even though a large amount of fluid is being put in, should not expect to get a lot of fluid out
Why is a burn patient at an increased risk for infection?
Function of white blood cells (WBCs) is defective
List the clinical manifestations of the emergent burn phase.
- Shock
- Pain
- Blisters
- Paralytic ileus
- Shivering
- Altered mental status
How would the nurse combat shock in a burn patient?
Fluid resuscitation
List the complications of a burn.
- Dehydration
- Shock
- Acute tubular necrosis
- Infection
What surgical procedure may be done to a patient with circumferential burns?
Escharotomy
What signs and symptoms indicate the acute phase of a burn has begun?
- Mobilization of extracellular fluid
- Diuresis
When does the acute phase of a burn end?
- Partial thickness wounds are healed
- Full thickness burns are covered by skin grafts
Which phase of the burn process is generally the longest?
Acute phase
What type of intentional wound healing occurs with partial thickness burns?
Secondary
What nursing interventions are provided to a burn patient during the acute phase?
- Wound care
- Pain management
- Nutritional therapy
What should nursing staff do before completing a dressing change on a burn wound that is open and exposed?
Don personal protective equipment (PPE)
What does scar tissue from a burn do to a patients range of motion (ROM)?
Scar tissue thickens and causes contracture’s
Why are splints used on a burn patient during the acute phase?
Maintain functionality
What type of device is used on a burn patient who has limited ROM and contractures?
Splint
What is an allograft?
Graft from the patient or self
What part of the body is an allograft usually taken from?
Thigh
What is a homograft?
Graft from a donor or cadaver
Each patient who suffers from a burn will receive what type of shot? This is considered what?
- Tetanus
- Preventative agent
Why might sedatives and anti-anxiety medications be given to burn patients?
- Prevent flashbacks of traumatic event
- Reduce anxiety developed around dressing changes
When are antibiotics given to a burn patient?
Infection presence is known
Why are antimicrobials used on burn patients?
Prevent large amounts of bacteria from forming
When would systemic antibiotics be given to a burn patient?
A diagnosis of sepsis is made
Due to burn patients being high risk for developing DVT and blood clots, what medication is given?
Low molecular weight heparin
What type of nursing interventions should be implemented to decrease risk of blood clots in a burn patient?
- Intermittent pneumatic compression devices
- Graduated compression stockings
After fluid needs have been met, what takes priority in a burn patient?
Nutrition
Does a large inflammatory response increase or decrease patient metabolism?
Increase
A burn patients metabolism can function _____ to ______ higher than normal.
50% to 100%
The specific breakdown of protein is known as what?
Catabolism
Why is early and aggressive nutritional support necessary in a burn patient?
- Decreases complications
- Decreases mortality
- Decreases negative effects of hypermetabolism
- Decreases catabolism
- Optimizes healing
Partial-thickness burns can convert to full-thickness wounds if what is present?
Infection
What laboratory level is assessed to aid in identifying sepsis?
Lactic acid
What does a lactic acid level assess?
-Oxygen delivery to tissues
List the signs and symptoms of sepsis.
- Increased heart rate
- Hypothermia or hyperthermia
- Decreased blood pressure
- Decreased urine output
What is a Curling’s ulcer?
A burn patient who has an ulcer
How do glucose levels affect wound healing?
Increased BGLs will slow wound healing
What type of therapy might a burn patient be receiving if their blood glucose level is elevated?
Insulin drip
When does the rehabilitation phase begin for burn patients?
- Wounds have nearly healed
- Patient is engaging in some self-care
Often skin _______ regain its original color.
Does not
When is mature healing reached?
12 months
Newly healed areas can be ___________ or ___________ to cold, heat, and touch.
Hypersensitive or hyposensitive
What is the most common complication during the rehabilitation phase for burn patients?
Skin and joint contractures
List interventions used to minimize skin and joint contractures.
- Proper positioning
- Splinting
- Exercise
Why should patients with burns involving the face, genitals, hands, feet, and major joints go to a burn center?
Maintain functionality
Why should patients with electrical burns go to a burn center?
Heart and kidney complications
Why should patients with inhalation burns go to a burn center?
Airway maintenance
Why should patients who have burn injuries with concomitant trauma go to a burn center?
Due to high stress traumatic events
Why should children with burn injuries go to a burn center?
Typically more severe
List the analgesics and sedatives commonly given to burn patients.
- Morphine
- Hydromorphone
- Haloperidol
- Lorazepam
- Midazolam
How are analgesics and sedatives administered to burn patients? Why?
- IV
- Fastest onset of action
List the topical antimicrobial agents most commonly given to burn patients.
- Silver sulfadiazine
- Mafenide acetate
What is the normal range for lactic acid?
0.6 - 2.2
What laboratory level is elevated in a patient with metabolic asphyxiation?
Carboxyhemoglobin levels
