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Thursday, November 1, 2007

Integumentary System :: Medical Surgical Nursing :: Review For Nursing Licensure Examination

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Integumentary System :: Medical Surgical Nursing :: Review For Nursing Licensure Examination Slide Transcript
Slide 1: Integumentary System Review Nurse Licensure Examination Review

Slide 2: Burns Definition: Cellular destruction of the layers of the skin and the resultant depletion of fluids and electrolytes. These are skin injuries resulting from various injurious factors.

Slide 4: Burns Burn injuries depend on: History of the injury Causative factor Temperature of the burning agent Duration of contact with the agent Thickness of the skin

Slide 5: Types of Burns according to ETIOLOGY 1. Thermal: most common type; caused by flame, flash, scalding, and contact (hot metals, grease)

Slide 6: Types of Burns according to ETIOLOGY 2. Smoke inhalation: occurs when smoke (particulate products of a fire, gases, and superheated air) causes respiratory tissue damage

Slide 7: Types of Burns according to ETIOLOGY 3. Chemical: caused by tissue contact, ingestion or inhalation of acids, alkalies, or vesicants

Slide 8: Types of Burns according to ETIOLOGY 4. Electrical: injury occurs from direct damage to nerves and vessels when an electric current passes through the body.

Slide 9: Types of Burns according to ETIOLOGY 5. Radiation Burns- This is caused by exposure to ultraviolet rays, x-rays and radioactive sources.

Slide 11: Burn classification as to depth Superficial Partial thickness (1st degree) Outer layer of dermis Erythema, pain up to 48 hrs Healing 1-2 wks [sunburn]

Slide 12: Burn classification as to depth Deep Partial thickness (2nd degree) Epidermis & dermis involved Blisters & edema, frequently quite painful Healing 14-21 days

Slide 13: Burn classification as to depth Full thickness (3rd degree) Epidermis, dermis, subcutaneous fat are involved Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting

Slide 15: ESTIMATION of BURNS Various methods are utilized for estimating the extent of burn injury 1. The Rule of Nines in adults Head and Neck- 9% Anterior trunk- 18% Posterior trunk- 18% Upper arms- 18% ( 9% each x 2) Lower ext- 36% ( 18% EACH X 2) Perineum- 1%

Slide 16: Burn estimation 2. LUND AND BROWDER or BERKOW method Modifies percentages for body segments according to age Provides a more accurate estimate of the burn size Uses a diagram of the body divided into sections, with the representative % of TBSA for all ages

Slide 17: PATHOPHYSIOLOGY OF BURNS Burns are caused by transfer of energy from a heat source to the body Tissue destruction results from COAGULATION, Protein denaturation, or Ionization of cellular contents from a thermal, radiation or chemical source.

Slide 18: PATHOPHYSIOLOGY OF BURNS Following burns, Vasoactive substances are released from the injured tissue and these substances cause an increase in the capillary permeability allowing the plasma to seep to the surrounding tissues

Slide 19: PATHOPHYSIOLOGY OF BURNS The generalized edema, evaporation of fluids and capillary membrane permeability result to DECREASED circulating blood volume

Slide 20: PATHOPHYSIOLOGY OF BURNS The decrease in blood volume results to decrease organ perfusion The blood volume decreases, BP and Cardiac output decrease and the body compensates by increasing heart rate The hematocrit level increases as a result of plasma loss

Slide 21: PATHOPHYSIOLOGY OF BURNS The body mobilizes compensatory mechanisms- blood is shunted from the kidney, skin and GIT to the BRAIN. Oliguria is expected, as well as intestinal ileus and GI dysfunction The immune system is depressed, resulting in immunosuppression and increased risk for infection

Slide 22: PATHOPHYSIOLOGY OF BURNS The pulmonary system may react by pulmonary vasoconstriction causing a decreased oxygen tension and pulmonary hypertension Tissue destruction initially causes HYPERKALEMIA because injured tissues release K+ HYPONATREMIA may be expected because of PLASMA LOSS (with Na+) into the interstitial space

Slide 23: Assessment Findings Superficial Partial Thickness Burns (1st)  Local erythema  No Blister formation  Mild local pain  Rapid healing WITHOUT scarring

Slide 24: Assessment Findings Deep Partial Thickness (2ND) Tissue destruction of epidermis- dermis Skin appears red to ivory, moist Wet, large and thin blisters Intact tactile and pain sensation, moderate to severe pain Healing is variable and with scarring

Slide 25: Assessment Findings Full Thickness Burns (THIRD DEGREE) Injury appears WHITE, or black, with thrombosed veins Dry, leathery appearance due to loss of epidermal elasticity Marked EDEMA Painless to touch due to destruction of superficial nerves

Slide 26: Burn Management 1.EMERGENT PHASE Begins at the time of injury and ends with the restoration of the capillary permeability ( with 48-72 hours) The GOAL is to PREVENT hypovolemic shock and preserve the vital body organ function Emergency and pre-hospital care

Slide 27: Burn Management 2.RESUSCITATIVE PHASE Begins with the initiation of fluids and ENDS when capillary integrity returns to near-normal and large fluid shifts have decreased The GOAL is to prevent shock by maintaining adequate circulating blood volume to maintain vital organ perfusion

Slide 28: Burn Management 3.ACUTE PHASE Begins when the client is HEMODYNAMICALLY stable, capillary permeability is restored and DIURESIS has begun Emphasis is placed on restorative therapy and the phase continues until wound closure is achieved The FOCUS is on infection control, wound care, wound closure, nutritional support, pain management and physical therapy

Slide 29: Burn Management 4.REHABILITATIVE PHASE The final phase of Burn care, restoration of functions, cosmetic surgery Goals of this phase – patient independence and restoration of maximal function

Slide 30: Medical Management Medical management 1. Supportive therapy: fluid management (lVFs), catheterization 2. Wound care: hydrotherapy, debridement (enzymatic or surgical)

Slide 31: Medical Management 3. Drug therapy a. Topical antibiotics: mafenide (Sulfamylon), silver sulfadiazine (Silvadene), silver nitrate, povidone-iodine (Betadine) solution b. Systemic antibiotics: gentamicin c. Tetanus toxoid or hyperimmune human tetanus globulin (burn wound good medium for anaerobic growth) d. Analgesics 4. Surgery: excision and grafting

Slide 32: Nursing Management 1. Emergent phase (time of injury) Remove person from source of burn. 1) Thermal: smother burn beginning with the head. 2) Smoke inhalation: ensure patent airway. 3) Chemical: remove clothing that contains chemical; lavage area with copious amounts of water. 4) Electrical: note victim position, identify entry/exit routes, maintain airway.

Slide 33: Nursing Management 1. Emergent phase (time of injury) Cool the burn for several minutes. DON’T USE ICE!! Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth and conserve body heat. Assess how and when burn occurred.

Slide 34: Nursing Management 1. Emergent phase (time of injury) Remove constricting clothes and jewelry Cover the wound with a sterile dressing or clean, dry cloth Provide IV route only if possible Transport immediately to a hospital or burn facility

Slide 35: Nursing Management 2. Resuscitative and Shock phase (first 24—48 hours) Provide appropriate fluid resuscitation based on the Parkland formula 4 mL Plain LR x %TBSA of burns x kg body weight

Slide 36: Nursing Management 3. Fluid remobilization or diuretic phase (2—5 days post burn) Monitor and treat potential complications like acute renal failure, paralytic ileus, Curling’s ulcer and hypokalemia

Slide 37: Nursing Management 4. Convalescent phase a. Starts when diuresis is completed and wound healing and coverage begin.

Slide 38: GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 1. Provide relief/control of pain. a. Administer morphine sulfate IV and monitor vital signs closely. b. Administer analgesics/narcotics 30 minutes before wound care. c. Position burned areas in proper alignment

Slide 39: GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 2. Monitor alterations in fluid and electrolyte balance. a. Assess for fluid shifts and electrolyte alterations b. Monitor Foley catheter output hourly (30 cc per hour desired). c. Weigh daily. d. Monitor circulation status regularly. e. Administer/monitor crystálloids/colloids

Slide 40: GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 3. Promote maximal nutritional status. a. Monitor tube feedings if Peripheral Nutrition is ordered. NPO immediately after injury!!! ONLY when oral intake permitted, provide high-calorie, high-protein, high- carbohydrate diet with vitamin and mineral supplements. c. Serve small portions. d. Schedule wound care and other treatments at least 1 hour before meals.

Slide 41: GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 4. Prevent wound infection. a. Place client in controlled sterile environment. b. Use hydrotherapy for no more than 30 minutes to prevent electrolyte loss. Observe wound for separation of eschar and cellulitis.

Slide 43: GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 5. Prevent GI complications. a. Assess for signs and symptoms of paralytic ileus. b. Assist with insertion of NG tube to prevent/control Curling’s/stress ulcer; monitor patency/drainage.

Slide 44: GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 5. Prevent GI complications. c. Administer prophylactic antacids through NG tube and/or IV cimetidine (Tagamet) or ranitidine (Zantac) (to prevent stress ulcer). d. Monitor bowel sounds. e. Test stools for occult blood.

Slide 45: Rehabilitation Methods of coping and re- socialization Ensure optimum nutrition Initiate physical therapy to regain and maintain optimal range of motion and achieve wound coverage Provide psychosocial support to promote mental health

Slide 46: Rehabilitation Provide family-centered care to promote integrity of the family as a unit Encourage post-discharge follow-up for several years Ensure appropriate referral to cosmetic surgeon, psychiatrist, occupational therapist, nutritionist and physical therapist

Slide 47: Drugs for Burns Mafenide (Sulfamylon) 1) Administer analgesics 30 minutes before application. 2) Monitor acid-base status and renal function studies. SIDE EFFECT: LACTIC ACIDOSIS 3) Provide daily BATH for removal of previously applied cream.

Slide 48: Drugs for Burns Silver sulfadiazine (Silvadene) 1) Administer analgesics 30 minutes before application. 2) Observe for and report hypersensitivity reactions (rash, itching, burning sensation in unburned areas). 3) Store drug away from heat

Slide 49: Drugs for Burns Silver nitrate 1) Handle carefully; solution leaves a gray or black stain on skin, clothing, and utensils. 2) Administer analgesic before application. 3) Keep dressings wet with solution; dryness increases the concentration and causes precipitation of silver salts in the wound.

Slide 50: Drugs for Burns Povidone-iodine (Betadine) Administer analgesics before application. Assess for metabolic acidosis/renal function Gentamicin Assess vestibular/auditory and renal functions at regular intervals. Cimetidine Given to prevent Curling’s ulcer

Slide 52: End of burns

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