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8/9/2019 Management of Client With Integumentary Disorders
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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 dermal papillae
RETE PEGS fingerlike projections of epidermal tissue
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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
Epidermal pigment producing cells
Produces MELANOSOMES (pigment granules) that contains MELANIN (skin pigment)
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
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Originally located at the bone marrow & migrate to the epidermis
Plays a role in the immune reactions of the skin can alert the immune system
Layers of the Epidermis
Stratum Germinativum
Basal cell layer
Stratum spinosum
Prickle layer
Stratum Granulosum
Nucleated granular cells
Stratum Lucidum
Thin transparent layer
Stratum Corneum
Horny layer of the dead keratinized cells
Vitamin D
activated in the epidermis by the UV light
distributed 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
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
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Hair follicles are located in the dermal layer
Toughness is caused by hair keratin rich in sulfur
Color- genetically determined by persons 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
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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 familys 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
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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;
Blood flow
Oxygenation
Body temperature
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;
Color
Size
Location
Configuration
3. Edema
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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
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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
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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. Woods 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
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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:
drugs
foods
infection
autoimmune disease
malignancies
physical stimuli
psychogenic responses
Treatment removal of triggering substances
antihistamine
avoid overexertion
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alcohol consumption
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
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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
In acute care setting
Long term care facility
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 clients 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
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turning & positioning every 2 hours
Assessment
History
identify cause & factors that may impair wound healing
contributing factors
Prolonged bedrest
Immobility
Incontinence
Inadequate nutrition or hydration
Altered mental status
Wound Assessment
assess
wound location
size, color & extent of wound involvement, cell types
presence exudates
condition of surrounding tissue
presence 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
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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 clients skin directly off plastic surfaces
keep the clients 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
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usually painless
Diagnosis
Appearance of the lesion
Culture
Anthrax antibodies
Biopsy
Treatment
Oral Antibiotics for 60 days
no edema, systemic symptoms, lesions not on the head & neck
Intravenous injections & 60 days oral antibiotics
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
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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
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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)
Has effect on the liver
A cytotoxic drug
Clyosporine (Sandimmune) & Azathioprine (Immuran) immunosuppressant
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Biologic Agents
Alefacept (Amevive) given IM weekly in 12 weeks
Efalizumab (Raptiva) given SQ once per week
4. Emotional Therapy
low self esteem due to lesions & treatment
touch communicates acceptance
BURNS
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 Alkalis or Acids
5. Electrical Injury
occur when an electrical current enters the body
called grand masqueder small surface may cause devastating internal injuries
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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
pink to red
mild edema
no blisters, eschar
healing time 3-5 days
no grafts required
Partial-Thickness/Second Degree Burn
pink to red
mild to moderate edema
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painful
presence of blisters
< 2 weeks healing time
scalds, flames, brief contact with hot objects
Full-Thickness/Third Degree Burn
Black, brown, yellow, red
with moderate edema
blisters rare
healing time 2-6 weeks
grafts required
Deep Full-Thickness/Fourth Degree Burn
black
absent edema & pain
hard & ineslactic eschar
weeks 2 months
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
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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
Curlings 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 1940s, a quick assessment tool in estimating burn size
the body is divided in anatomical sections, each represents 9 or a multiple of 9
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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 patients 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 patients 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 ABCs.
Establish airway
Ensure adequate breathing.
Assess circulation.
c) Assess for associated trauma.
d) Conserve body heat.
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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 ABCs
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
Blood Exam
- WBC, HGB, HCT, BUN, K, Cl
- Na, Total CHON, Albumin
Others
CT scan, UTZ, Bronchoscopy, MRI
2) Initiation of Fluid Resuscitation
maintain vital organ perfusion
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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
given in 8 hours
given in 16 hours
IVF used: Lactated Ringers 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
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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
in 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
Because of infection the use of plastic liners and thorough decontamination of hydrotherapy
equipment and wound care areas are necessary to prevent cross contamination.
Tap water alone can be used for burn wound cleansing
Hydrotherapy provides an excellent avenue for the patient to exercise and clean the entire body
Hair in and around burn areas must be clipped short.
Intact blister may be left, but the fluid should be aspirated with a needle and syringe discarded.
Wound cleaning is usually performed at least daily in wound areas that are not undergoing
surgical interventions
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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 beendesigned 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 patients 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.
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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 patients 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
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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 withminimal 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.
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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
patients own skin and thus are not rejected by the patients 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
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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.