MANAGEMENT OF CLIENT WITH INTEGUMENTARY DISORDERS

Prepared By: Ms. Lydia C. Mactal, RN, MSN

REVIEW OF ANATOMY & PHYSIOLOGY

A. Structure of the skin

1. Subcutaneous Fat

 Adipose tissue

 Innermost layer of the skin

 Lies over the muscle and the bone

 Site of fat formation & storage.

 Serves as an energy reserve

 Heat insulator of the body

 Absorbed and protect shock against injury by padding internal structures

 Fat distribution varies with body area, age and gender

2. Dermis

 A layer of connective tissue that contains no cells

Collagen – main component of dermal tissue; formed by the FIBROBLAST ; increases production in
areas of tissue injury & helps in the formation of scar

 Houses network of capillaries and lymph vessels in the exchange of oxygen & heat.

 Rich in sensory nerves that transmit the sensation of touch, pressure, temperature, pain &
itch

 Composed of collagen & elastic fibers that are interwoven

3. Epidermis

 Outermost skin layer

 Anchored to the dermis by fingerlike projections of dermal tissue ð dermal papillae

 RETE PEGS ð fingerlike projections of epidermal tissue

  Does not have separate blood supply

 Receives nutrients by diffusion in the porous basement membranes at the dermal-epidermal

junction

 Thin, stratified outer skin layer in direct contact with the external environment

 Thickness ranges from:

 Eyelids : 0.04mm

 Palms & soles : 1.6mm

 Four Cell types

 Keratinocytes

 Principal cells of the epidermis

 Produces KERATIN

 Epidermis constantly regenerates itself providing a though keratinized barrier

 Melanocytes

ÄEpidermal pigment – producing cells

Ä Produces MELANOSOMES (pigment granules) that contains MELANIN (skin pigment)

Ä Four pigments that determine skin color

 yellow – exogenously produced carotenoids

 brown – melanin

 blue – reduced Hgb in venules

 red – oxygenated Hgb in capillaries

 Merkel cells

 Found in the basal layer

 The touch receptors on palms, soles, oral & genital epithelium but very scarce

 Can be located by the use of electron microscope

 Langerhans Cells

 Scattered among the keratinocytes located primarily at the dermis

  Originally located at the bone marrow & migrate to the epidermis

 Plays a role in the immune reactions of the skin ð can alert the immune system

Layers of the Epidermis

®Stratum Germinativum

Ä Basal cell layer

® Stratum spinosum

ÄPrickle layer

® Stratum Granulosum

Ä Nucleated granular cells

® Stratum Lucidum

Ä Thin transparent layer

® Stratum Corneum

Ä Horny layer of the dead keratinized cells

 Vitamin D

ð activated in the epidermis by the UV light

ðdistributed by the blood to the other areas of the body.

 Darker skin tones are not caused by increase number of melanocytes rather the size of the
pigment granules (melanin) contained in each cell determines the color.

 Freckles, birthmarks, age spots

ð patches of melanin with in the skin

SKIN APPENDAGES

® HAIR

 A nonviable CHON end found on all skin surfaces except on palms & soles

 Growth varies with race, gender, age and genetic predisposition

 Individual hairs can differ in both structures & rate of growth depending on body location
  Hair follicles are located in the dermal layer

 Toughness is caused by hair keratin rich in sulfur

 Color- genetically determined by person’s rate of melanin production

 Hair growth cycles

 ANAGEN – growth phase

 TELOGEN – resting phase

® Nails

 Horny scales of the epidermis

 Parts:

 LUNULA – white crescent- shaped portion at the lower end of the nail plate

 NAIL MATRIX – source of non-keratinized cells; located at the proximal nail bed

 CUTICLE – attaches the nail plate; layer of keratin at the nail fold

 Nail growth is a continous but a slow process

 Growth rate:

 Fingernails: 3 to 4 months

 Toe nails: 12 months

Glands

1. Sebaceous glands

 Found throughout the skin except palms & soles

 Directly connected at the hair follicle

 Freestanding: eyelids, nipple & genitalia

 Produces SEBUM – mildly bacteriostatic fat containing substance; lubricates the skin &
reduces H20 loss

2. Sweat Glands

® Eccrine glands
  sweat producing glands that play an important role in thermoregulation

 Numerous in palms, soles, forehead and axillae

 Odorless, isotonic secretion

 Can lose up to 10 to 12 liters of fluid/single day

 Main stimulus for secretion is HEAT or can be caused by exercise & emotional stress

® Apocrine glands

 have direct contact with the hair follicle

 Found in axillae, perineal, areola & periumbilical area

 odor is caused by the interaction of skin bacteria with the secretions

ASSESSMENT

A. Demographic Data

▪ Age – changes could be normal in color adult

 Race & Nationality – normal/abnormal with specific race & ethnicity

 Occupation – chemicals, irritants, abrasive substances & environmental skin problems

B. Family History & Genetic Risk

▪ skin disorders have a familial predisposition

▪ explore family’s tendency for chronic skin problems

▪ current skin status

C. Personal History

▪ medical history

▪ previous & current illness

D. Medication History

▪ use of prescription and OTC

▪ time drug started, dose & frequency, time dose taken

E. Current Health problems

F. Diet History

• weight, height, body fluid & food preferences

 Poor nutrition, CHON deficiency & vitamin deficiency, obesity

G. Socioeconomic Status

 social & economic background

Skin Assessment

A. Inspection

1. Color

▪ can be affected by;

Ä Blood flow

Ä Oxygenation

Ä Body temperature

Ä Pigment production

▪ changes can be generalized or localized

▪ can be observed in oral mucosa, sclera, nail beds and palms, soles

2. Lesions

▪ described as;

®Primary lesion – initial reaction

® Secondary lesion – occur after the initial reaction

▪ describe interms of;

ÄColor

Ä Size

Ä Location

Ä Configuration

3. Edema
▪ appear shiny, taut and pale

 ▪ document location, distribution and color

4. Moisture

▪ note for the thickness and consistency of secretion

▪ excess moisture

Cause skin breakdown

Decreased air circulation

5. Vascular markings

▪ normal – birthmarks, angiomas (spider & cherry) and venous stars

▪ abnormal – caused by bleeding into the tissue

▪ Petchiae

▪ Ecchymosis

6. Integrity

▪ examine actual breaks

7. Cleanliness

B. Palpation

▪ gather additional information

▪ confirm size of the lesion (flat or raised)

▪ make hands warm before palpation

▪ assess texture which differs according to body parts

 ▪ Turgor

– indicates the amount of skin elasticity

- assess for “tenting”

- older client chest at the forehead or chest

Hair Assessment
  ▪ inspect and palpate for cleanliness, distribution, quantity and quality

 ▪ inspect the scalp for scaling, redness, lesions, excoriation, crusting and tenderness

 ▪ Hirsutism - excessive hair growth

Nail Assessment

 Color

▪ inspect for thickness and transparency, amount of RBC, arterial blood flow & pigment deposits

▪ could be caused by external factors (chemical or occupational)

 Shape

▪ indicate early or late changes

 Thickness

 Consistency

▪ described as hard, soft or brittle

▪ soft nail plate – caused by malnutrition, chronic arthritis, myxedema

▪ brittle nails – onychomycosis or advanced psoriasis

 Lesions

▪ oncholysis – common with fungal infections and after trauma

▪ inspect for soft tissue folds around nail plate for redness, heat, swelling and tenderness

Diagnostic Assessment

 Laboratory Tests

1. Culture

a. Culture for Fungal infections

▪ KOH – potassium hydroxide

- positive examination eliminates culture

b. Culture for Bacterial Infection

 ▪ obtained from lesions

c. Culture for Viral Infections

▪ are indicated for a herpes virus infection

 Other Diagnostic Tests

a. Skin Biopsy

▪ a small piece of skin tissue for pathologic study

▪ types:

 Punch Biopsy

- uses punch (a small circular cutting instrument)

 Shave Biopsy- removes a portion of the skin is elevated

- scalpel or razor is moved parallel to the skin

 Excisional Biopsy – larger or deeper specimens

c. Wood’s Light examination

▪ a handheld, long-wave UV light

 ▪ infected skin produces blue-green or red

d. Diascopy

▪ a glass slide or lens is pressed down over the area to be examined, blanching the skin to reveal
the shape of the lesions

e. Skin Testing

MINOR SKIN PROBLEMS

A. DRYNESS

 ▪ Xerosis

 ▪ common in older adult

 ▪ flaking of the stratum corneum

 ▪ generalized pruritus
  ▪ Causes:

Äcentral heating or airconditioning

Ä wind, cold & sunlight

Ä frequent bathing with harsh soap & hot water

 ▪ Management

1) Bathing with moisturizing soap, oils and lotions.

2) Encourage application of skin creams or lotions.

3) Avoid constricting clothing.

4) Rinse thoroughly after bath.

5) Maintain daily fluid intake of 1-3 liters/day unless contraindicated

6) Do not apply rubbing alcohol, astringents or other drying agents.

B. PRURITUS

 ▪ itching, a distressing symptom that may or may not occur with skin disease

 ▪ subjective symptom as pain; varies among client in location & severity

 ▪ usually worse during the night

 ▪ poor skin hydration, increase temperature, perspiration & emotional stress

 ▪ Management

 Plan is to provide comfort & maintain skin integrity.

 proper bathing & skin lubrication

 fingernails should be kept short

 wearing of mittens during the night

 use of therapeutic bath

 antihistamines & anti-inflammatory drugs are administered

C. SUNBURN
  ▪ a first-degree or superficial burn

 ▪ common skin injury

 ▪ excessive exposure to UV injures the dermis

 ▪ S/S : tenderness, edema, occasional blister formation

 ▪ redness (erythema) & pain begin within few hours

 ▪ treatment towards comfort

cool baths

soothing lotions

antibiotics ointment for blisters

corticosteroids for severe pain

D. URTICARIA

 ▪ hives

 ▪ presence of white or red edematous papules or plaques of various size

 ▪ factors:

Ädrugs

Ä foods

Ä infection

Ä autoimmune disease

Ä malignancies

Ä physical stimuli

Ä psychogenic responses

 ▪ Treatment removal of triggering substances

Ä antihistamine

Ä avoid overexertion
 Ä alcohol consumption

Ä warm environment

PRESSURE ULCERS

 ▪ tissue damage caused when the skin and underlying soft tissue are compressed between bony
prominences and external surface for a extended period of time

 ▪ referred as decubitus ulcer, pressure ulcer

 ▪ commonly occur over the sacrum, hips and ankles

 ▪ commonly occur in people limited mobility and sensory impairment

 Stages

1. Stage I

changes in color (red, blue, purple), temperature (warm or cold)

2. Stage II

partial-thickness loss of skin involving Epidermis & part of Dermis

3. Stage III

full-thickness skin loss involving subcutaneous damage or necrosis

4. Stage IV

full-thickness skin loss with severe destruction, necrosis or damage to muscle, bone or supporting
structures

Causes:

 pressure

▪ occurs as a result of gravity

▪ can compress blood vessel that may lead to ischemia, inflammation & tissue necrosis

 friction

▪ surfaces rub the skin and initiate or directly pull off epithelial tissue

▪ patient is dragged or pulled across bed linen

 shear
▪ generated when the skin itself is stationary and the tissue below the skin shift or move

▪ occur when the client in a semi-sitting position and gradually slides

 excessive skin moisture

 nutritional status

Incidence/Prevalence

Ä In acute care setting

Ä Long term care facility

Ä Home care setting

 Prevention/Health Promotion

“ An ounce of prevention may be worth tons rather than pounds of cure”.

A. Identification of High Risk Clients

1. Activity/ Mobility

▪ level of client’s independent mobility

2. Nutritional Status

▪ includes laboratory studies

▪ evaluation of weight & weight change

3. Incontinence

B. Implementation of pressure relief or reduction devices

 Pressure-relief Devices

▪ consistently reduce pressure

 Pressure-reduction Devices

▪ lower pressure than that of the standard hospital devices

 Positioning

 ▪ 30-degree rule
  ▪ turning & positioning every 2 hours

Assessment

 History

▪ identify cause & factors that may impair wound healing

▪ contributing factors

Ä Prolonged bedrest

Ä Immobility

Ä Incontinence

Ä Inadequate nutrition or hydration

Ä Altered mental status

 Wound Assessment

▪ assess

Äwound location

Ä size, color & extent of wound involvement, cell types

Äpresence exudates

Äcondition of surrounding tissue

Äpresence of foreign body

• record location, size of wound

• Psychological Assessment

▪ client may have altered body image

▪ client and family knowledge of treatment goals

▪ strict adherence to pressure ulcer care

 Laboratory Assessment

▪ culture & sensitivity

▪ swab culture
 ▪ blood examination

 Management

1. Positioning

▪ keep the head of the bed elevated at 30 degrees angle

▪ use a lift sheet to move client in bed

▪ change position every 2 hours

▪ place pillows or foam wedges between 2 bony prominences

▪keep the client’s skin directly off plastic surfaces

▪ keep the client’s heel off the bed surface

2. Nutrition

▪ maintain adequate intake of CHO and calories

▪ adequate fluid intake

3. Skin Care

▪ keep areas where two skin surfaces touch (breast, axillae)

▪ clean the skin ASAP after soiling and at routine interval

▪ Use mild soap & apply lotions

▪ Use tepid water instead of hot water

▪ gently pat the skin rather than rub when drying.

CUTANEOUS ANTHRAX

 ▪ caused by Bacillus Anthracis

 ▪ may be confined to skin or systemic

 ▪ vesicles appears, itchy and resembles as an insect bite

 ▪ the vesicles become hemorrhagic & sinks inward

 ▪ necrosis & ulceration begins

  ▪ usually painless

 ▪ Diagnosis

ÄAppearance of the lesion

ÄCulture

ÄAnthrax antibodies

ÄBiopsy

 ▪ Treatment

Oral Antibiotics for 60 days

Ä no edema, systemic symptoms, lesions not on the head & neck

Intravenous injections & 60 days oral antibiotics

Ä pregnant, fever, lesions on the head & neck, excessive edema

 Drug of choice

Ciprofloxacin (Ciprobay)

Doxocycline (Doxin, Vibramycin)

PARASITIC DISORDERS

A. Pediculosis

▪ infestation of human lice

▪ oval, 2 to 4mm long

▪ types

1. Pediculosis Capitis

▪ head lice

2. Pediculosis Corporis

▪ body lice

▪ sign: excoriation on the trunk, abdomen or extremities

3. Pediculosis Pubis
 ▪ pubic, crab, lice

▪ causes intense itching on the vulvar or perirectal region

▪ contracted with infested bed linens or sexual intercourse

 Interventions

▪ chemical killing with Lindane (Kwell) or topical malathion (Ovide, Prioderm)

▪ clothing and linens should be washed with hot water or dry cleaned

▪ use of fine toothed comb

▪ social contacts

B. Scabies

 ▪ contagious disease caused by mite infection

 ▪ can be transmitted by close & prolonged contacts

 ▪ common with poor hygiene & crowded living conditions

 ▪ can be carried by pets & among school children

 ▪ itching is more intense and more during the night

 ▪ occur in the curved or linear ridges of the skin

 ▪ mites & eggs can be seen under the microscope

 ▪ treatment: Scabicides (lindane) or sulfur preparation

PSORIASIS

 ▪ a lifelong disorder that has exacerbation and remissions

 ▪ scaling disorder with underlying inflammation

 ▪ there is abnormality in the growth of epidermal cells (usually shed every 4 to 5 days)

 ▪ No cure but can actively control symptoms

 Etiology and Genetic Risk

 ▪ autoimmune reaction resulting from the over stimulation of the immune system

 ▪ genetic predisposition can be considered

  ▪ no family history

Types

1. Psoriasis Vulgaris

▪ most common

▪ presents as thick reddened papules or plaques covered by silvery white scales

▪ borders between the lesions and normal skin are sharply defined

▪ sites: scalp, elbows, trunk, knees, sacrum, surfaces of the limb

2. Exfoliative Psoriasis

▪ erythrodermic psoriasis

▪ an explosively eruptive and inflammatory form with generalized erythema and scaling

▪ do not form obvious lesions

▪ watch out for dehydration, hypothermia or hyperthermia

 Interventions

1. Topical Therapy

▪ Corticosteroids suppresses cell division

▪ effectiveness is based on potency and ability to be absorbed

2. Tar preparations

▪ applied in the skin

▪ suppresses cell division and reduces inflammation

3. Ultraviolet Light Therapy

▪ physical agent that is used as a topical treatment

3. Systemic therapy

▪ methotrexate (Folex, Mexate)

ÄHas effect on the liver

ÄA cytotoxic drug

▪ Clyosporine (Sandimmune) & Azathioprine (Immuran) – immunosuppressant

 ▪ Biologic Agents

ÄAlefacept (Amevive) – given IM weekly in 12 weeks

ÄEfalizumab (Raptiva) – given SQ once per week

4. Emotional Therapy

▪ low self esteem due to lesions & treatment

▪ touch communicates acceptance

BURNS

Ä attributed to extreme heat sources and from exposure to cold, chemicals, electricity or radiation

 Etiology of Burn Injury

1. Dry Heat

▪ injuries caused by open flame

▪ house fire and explosions

2. Moist Heat

▪ scald

▪ contact with hot fluids or steam

3. Contact Burns

▪ hot metal, tar & grease when in contact with the skin

▪ occur in industrial settings

4. Chemical Injury

▪ occur as a result of accidents in homes or industry

▪ severity depends on the duration of contact, concentration of the chemicals, amount and action
of the chemical

▪ can be Alkali’s or Acids

5. Electrical Injury

▪ occur when an electrical current enters the body

▪ called “grand masqueder” – small surface may cause devastating internal injuries
 ▪ extent of injury depend on the type of current, pathway of flow, tissue resistance and duration
or contact

6. Radiation Injury

▪ large doses of radioactive material

▪ injury is usually minor & rarely cause extensive skin damage

INCIDENCE OF BURN INJURY

 Young children and elderly people are at particularly high risk for burn injury.

 Most burn injuries occur at home, usually at the kitchen while cooking or in the bathroom by
improper use of electrical appliances

 Many burns are preventable

 There are 4 major goals related to burns:

1. Prevention

2. Institution of lifesaving measures for the severely burned person

3. Prevention of disability and disfigurement through, early, specialized, individualized treatment

4. Rehabilitation through reconstructive surgery and rehabilitative programs

Classification of Burns

 Superficial/ First Degree Burn

Ä pink to red

Ä mild edema

Ä no blisters, eschar

Ä healing time 3-5 days

Ä no grafts required

 Partial-Thickness/Second Degree Burn

Ä pink to red

Ä mild to moderate edema

 Ä painful

Ä presence of blisters

Ä < 2 weeks healing time

Ä scalds, flames, brief contact with hot objects

 Full-Thickness/Third Degree Burn

Ä Black, brown, yellow, red

Ä with moderate edema

Ä blisters – rare

Ä healing time 2-6 weeks

Ä grafts required

 Deep Full-Thickness/Fourth Degree Burn

Ä black

Ä absent edema & pain

Ä hard & ineslactic eschar

Ä weeks 2 months

Ä grafts needed

PATHOPHYSIOLOGY

CHANGES

A. Vascular Changes

1. Fluid Shift

 ▪ also known as third spacing or capillary leak syndrome

 ▪ a continuous leak of plasma from the vascular space to the interstitial space

 ▪ causes loss of plasma fluids & CHO decreases blood volume & blood pressure

 ▪ extensive edema and weight gain occurs in the 1st 12 hours up to 24-36 hours

 ▪ Hemoconcentration develops
2. Fluid Remobilization

 ▪ after 24 hours, capillary leaks stops & restores capillary integrity

 ▪ edema fluid shift from interstitial space to vascular space

 ▪ blood volume increases thus increasing renal flow & diuresis

 ▪ Hyponatremia – increased renal excretion & lost of Na in wounds

 ▪ Hypokalemia – K moving back into the cells & excreted into the urine

B. Cardiac Changes

 ▪ 18 to 36 hours – heart rate increases & decreases cardiac output

 ▪ CA increases in fluid resuscitation

C. Pulmonary Changes

▪ results from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns & carbon
monoxide poisoning

D. Gastrointestinal Changes

 ▪ lesser blood flow thus decreased perfusion

 ▪ Peristalsis decreases from the stimulation of SNS as a stress response

 ▪ Curling’s ulcer develops in 24 hours due to reduced GI flow & mucosal drainage

E. Metabolic Changes

 ▪ Hypermetabolism – increase secretion of cathecolamines, ADH, aldosterone & cortisol

F. Immunologic Changes

 ▪ injury activates inflammatory response that suppresses immune function

 ▪ protective barrier is damaged, increasing the risk of infection

ESTIMATING BODY SURFACE AREA INJURED

1. Rule of Nine

 ▪ introduced in the 1940’s, a quick assessment tool in estimating burn size

 ▪ the body is divided in anatomical sections, each represents 9 or a multiple of 9

2. Lund and Browder Method

 ▪ a more precise of estimating extent of injured area, which recognizes that the percentage of BSA
of various anatomic area changes with growth

 ▪ The initial evaluation is made on the patient’s arrival and is revised on the second and third
postburn days.

3. Palm Method

 ▪ It is used if the client suffered from scattered burn. The size of the patient’s palm is
approximately 1% of BSA.

 ▪ The size of the palm can be used to estimate the extent of the burn injury

PHASES OF BURN INJURY

A. EMERGENT PHASE

 ▪ first phase

 ▪ begins at the onset of injury up to the 1st 48 hours

1. Pre-hospital care

 ▪ Guidelines:

a) Remove the victim from the source of the burn.

 ▪ Extinguish burning clothes.

 ▪ Remove saturated clothing (chemical or scald burn)

 ▪ Irrigate a chemical burn.

 ▪ Turn off electricity or remove electrical source using dry nonconductive object.

b) Assess the ABC’s.

 ▪ Establish airway

 ▪ Ensure adequate breathing.

 ▪ Assess circulation.

c) Assess for associated trauma.

d) Conserve body heat.

e) Consider need for IV administration

f) Transport

 Emergency Department

 Minor Burns

▪ pain management

▪ tetanus prophylaxis

▪ initial wound care

▪ teaching

 Major Burns

1) evaluation or reevaluation of ABC’s

2) Assessment

History – directly from the patient; if not to the witness

- demographic data (age, weight (preburn), height)

- health history

Skin – to determine size & depth

Laboratory

ÄBlood Exam

á - WBC, HGB, HCT, BUN, K, Cl

â - Na, Total CHON, Albumin

Ä Others

CT scan, UTZ, Bronchoscopy, MRI

2) Initiation of Fluid Resuscitation

▪ maintain vital organ perfusion

 ▪ formulas to calculate fluid requirements (Evans, Brooke, Modified Brooke, Parkland,
Hypertonic Saline solution)

▪ signs of adequate fluid resuscitation – stable vital signs, adequate urine output, palpable pulses,
clear sensorium

}FLUID REPLACEMENT FORMULAS ARE CALCULATED FROM THE TIME OF

INJURY NOT ON THE TIME OF ARRIVAL.~

Most commonly used:

Parkland Formula

4mg x TBSA burn x 24

½ given in 8 hours

½ given in 16 hours

IVF used: Lactated Ringer’s solution

ex. Mr. A burned at about 50% TBSA

4 x 50 x 24 = 4800

2400 cc LR given in 8 hours

2400 cc LR given in 16 hours

3. Placement of IFC

 ▪ measurement of hourly urine output

 ▪ urine output reliable indicator for adequacy of fluid resuscitation

4. Placement of NGT

 ▪ prevention of emesis and decrease risk for aspiration

5. Vital signs/ Baseline laboratory studies

 ▪ blood glucose, BUN, Creatinine, serum electrolytes, hematocrit level

6. Pain Management

 ▪ pain management on IV routes

 ▪ IM, SQ & oral route is not used

7. Tetanus prophylaxis
8. Data Collection

 ▪ important responsibility of the ER team

9. Wound Care

 ▪ cover the wound in clean dry sheet

 ▪ transport to proper facilities (burn unit)

Surgical Management

B. ACUTE PHASE

 ▪ begins 39 to 48 hours after injury and lasts until wound closure is complete

 Management

1. Infection Control

2. Wound Care

 ▪ aimed to promote wound healing

®Hydrotherapy

Hydrotherapy

 Äin the form of shower carts, individual showers, and bed baths can be used to clean the wounds.
It should be limited to a 20 to 30 minute period to prevent chilling and additional metabolic stress

 ÄBecause of infection the use of plastic liners and thorough decontamination of hydrotherapy
equipment and wound care areas are necessary to prevent cross contamination.

 ÄTap water alone can be used for burn wound cleansing

 ÄHydrotherapy provides an excellent avenue for the patient to exercise and clean the entire body

 ÄHair in and around burn areas must be clipped short.

 ÄIntact blister may be left, but the fluid should be aspirated with a needle and syringe discarded.

 ÄWound cleaning is usually performed at least daily in wound areas that are not undergoing
surgical interventions
TOPICAL ANTIBIOTIC THERAPY

 Topical antibiotics does not sterilize the burn wound they reduce the number of bacteria so that
the overall microbial population is controlled.

 Criteria for choosing include the following:

 It is effective against gram negative organisms

 It is clinically effective

 It penetrates the eschar but it is not systematically toxic

 It does not lose its effectiveness, allowing another infection to happen/develop

 It is cost-effective, available and acceptable

 It is easy to apply, minimizing nursing care time.

 The 3 most commonly used are: Silver sulfadiazine, silver nitrate and mafenide acetate. Before a
topical agent is re-applied, the previously applied should be removed

WOUND DRESSING

 When the wound is clean, the burned area are patted dry and the prescribed topical agent is
applied; the wound is then covered with several layers of dressings.

 A light dressing is used over joint to allow for movement and over areas which a splint has been
designed to conform to the body contour for proper positioning.

 Circumferential dressings should be applied distally to proximally.

 If the hand or toes are burned, they should be wrapped individually to promote adequate healing

EXPOSURE METHOD

 Wound is treated by exposing to air

 The success of the exposure method depends on keeping the immediate environment free from
organisms.

 Everything that comes in contact with the patient should be clean or sterile

 The patient’s room must be maintained at a comfortably warm temperature with 40% to 50%
humidity to prevent evaporation of fluid as well as to maintain body temperature.
  A cradle may be placed over the patient to prevent sheets from coming in contact with the burn
area, to minimize air currents, and to provide some covering

OCCLUSIVE METHOD

 An occlusive dressing is a thin gauze that is either impregnated with a topical antimicrobial or
that is applied after topical antimicrobial application.

 Occlusive dressings are most often used over areas with new skin grafts. These dressings are
applied under sterile conditions in the OT.

 Their purpose is to protect the graft, promoting an optimal condition for its adherence to the
recipient site.

 This dressings remain in place for 3 to 5 days.

 Functional body alignment positions are maintained by using splints or by careful positioning of
the patient.

DRESSING CHANGES

 Dressings are changed in the patient’s unit, in the hydrotherapy room, or treatment room area
approximately 20 minutes after the administration of analgesics

 The outer dressings are slit with blunt scissors, and the soiled dressings are removed and disposed
according of in accordance with established procedure.

 Dressings that adhere to the wound can be removed more comfortably if they are moistened with
saline solution or if the patient is allowed to soak for a few moments in the tub.

 The remaining dressings are carefully removed with forceps or gloved hands.

 The wound is then clean and debride to remove debris, or remaining topical antibiotics

 Inspect the skin for color, odor, size, exudates, signs of reepethelialization, and other
characteristics of the wound and the eschar and any changes from previous change of dressings.

WOUND DEBRIDEMENT

 GOALS: To remove tissue contaminated by bacteria and foreign bodies, thereby protecting the
patient from invasion of bacteria

 To remove devitalized tissue or burn eschar in preparation for grafting and wound healing
  TYPES OF DEBRIDEMENT

 1. NATURAL DEBRIDEMENT- The dead tissue separates from the underlying viable tissue,
spontaneously

 2. MECHANICAL DEBRIDEMENT – Involves using surgical and forceps to separate and

remove the eschar and usually done with the daily dressing change and wound cleaning
procedures

 3. SURGICAL DEBRIDEMENT – Is an operative procedure involving either primary excision

of the full thickness of the skin down to the fascia or shaving the burned skin layers gradually
down to freely bleeding.

 Surgical excision is initiated early in the burn wound management

 The use of surgical excision carries with it risks and complications, especially with large burns.
The procedure creates a high risk of extensive blood loss and lengthy operating and anesthesia
time

GRAFTING THE BURN WOUND

 1. Autograft

 Purpose: To decrease the risk for infection, prevent further loss of protein, fluid and electrolytes
and minimize heat loss.

 The main areas of skin grafting include the g=face, for cosmetic and psychological reasons; the
hands and other functional areas such as the feet; and the areas that involve the joints

 Grafting permits earlier functional ability and to reduce contractures.

BILOGIC DRESSINGS (Homografts and Heterografts)

 Biological grafts is lifesaving by providing temporary wound closure and protecting the
granulation tissue until autograft is possible.

 It may also be used to debride untidy wounds after eschar separation.

 Once the biological dressings appears to be “taking” or adhering to the granulating surface with
minimal exudates then the patient is ready for autograft.

 Biological dressings also provide immediate coverage for clean, superBiologic dressings consist
of homografts (allograft) and heterograft (xenograft)

 Homograft are skin obtained from living or recently deceased humans. Tends to more expensive
and they are available from skin banks.
  Heterografts consist of skin taken from animals. It thought to provide the best infection control of
all biologic or biosynthetic dressings available

BIOSYNTHETIC AND SYNTHETIC DRESSINGS

 The most widely used synthetic dressing is Biobrane, which is composed of a nylon, silastic
membrane combined with collagen derivative.

 Artificial skin (Integra) is the newest type of synthetic dressing.

 AUTOGRAFTS Are the ideal means of covering the burn wounds because they come from the
patient’s own skin and thus are not rejected by the patient’s immune system.

CARE OF PATIENT WITH AUTOGRAFT

 Occlusive dressings are commonly used initially after grafting to immobilize the graft.

 The first dressing change is usually done by the surgeon 3 to 5 days after surgery

 The patient is positioned and turned carefully to avoid disturbing the graft, it is elevated to
minimize edema.

 The patient begins exercising the grafted area after 5 to 7 days

CARE OF THE DONOR SITE

 A moist gauze dressing is applied at the time of surgery to maintain pressure and to stop any
oozing.

 A thrombostatic agents such as thrombin may be applied directly to the site as well.

 The donor site must remain clean, dry, and free from pressure.

 It will heal spontaneously within 7 to 14 days with proper care

PAIN MANAGEMENT

 Bolus doses of opiod, usually morphine, are often provided.

 Ketamine anesthesia administered IV is also used for some wound care procedures in burn units,

 Sedation with ant-anxiety medications such as lorazepam or midazolam may be indicated in

addition to analgesia
  PCA, using both continuous and bolus morphine sulfate infusions, and sustained-release oral
morphine, given every 12 hours with an additional dose before wound care

 Self-administered nitrous oxide helps to make dressing changes more tolerable

NUTRITIONAL THERAPY

 Goal is to promote a state of positive nitrogen balance.

 Protein requirements may range from 1.5 to 4 g/kg/day. Lipids is also included. Carbohydrates is
included to meet caloric requirement as high as 5,000cal/day. With adequate vitamins and
minerals.

DISORDERS OF WOUND HEALING

1. SCAR – Healing of such deep wounds results in the replacement of normal integument with highly
metabolically active tissues that lack the normal architecture of the skin.

2. KELOIDS – A large-heaped-up mass of scar tissue, a keloid may develop and extend beyond the
wound surface. Keloids tends to be found in darkly pigmented people, tend to grow outside wound
margins and are more likely to recur after surgical excision.

3. FAILURE TO HEAL

4. CONTRACTURES – The burn wound tissue shortens because of the force exerted by the fibroblasts
and the flexion of muscles in natural wound healing

 An opposing force provided by traction, splints, and purposeful movement and positioning must
be used to counteract deformity in burns affecting joints.