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87 Cards in this Set
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Review skin care and nursing care for pressure ulcers |
decubitus Ulcers are Ischemic lesions of the skin and underlying tissue caused by external ressure that impairs flow of blood and lymph. Ischemia causes tissue necrosis and eventual ulceration. Bony prominences very susceptible (Hells |
sacrum
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Shearing
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happens when one tissue layer slides over another. Lift clients with draw sheet. DO NOT slide client up the bed. GOOD BODY MECHANICS. Shear force or force created when the skin of a pt stays in one place as the deep fascia and skeletal muscle slide down with gravity. This can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis. Bedridden patients and wheelchair users in half-sitting position are very vulnerable for shear wounds. |
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Most at risk for pressure ulcers
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quadriplegic pts |
critical care pts
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Pressure Ulcer Staging
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Stage 1: Intact skin nonblanchable redness of localized area; usually over a bony prominence. Darkly pigmented skin may not have visible blanching; color may differ from surrounding area. Stage 2: Partial-thickness loss of dermis |
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NURSING CARE Dx
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risk for impaired skin integrity or impaired skin integrity. Must identify pts at risk and take preventative measures. Systemic risk assessments using validated tool such as the Braden scale. Systematic skin assessment at least once a day. Clean skin when soiled or at routine intervals or when client needs or preference dictates. Avoid hot water and apply as little force and friction as possible. Keep hydrated ~ low humidity and exposure to cold and dry skin is more susceptible to mechanical trauma. Use moisturizers.Provide sufficient dietary intake of protein and calories. Maintain client's current level of activity mobility |
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How do you assess skin problems for the client of African American descent?
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In dark skin clients paleness is dull, may be darker with cyansis. Jaqundice on palms sclera |
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What factors would affect changes in the color of a person's skin
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? |
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Psoriasis - what is occurring with this disorder & What is the treatment of this condition? |
Psoriasis- benign chronic inflammatory skin condition. Raised reddened round circumscribed plaques of varied sizes covered by silvery white scales. Condition worsened w sunlight stress emotional distress hormone changes certain drugs. Cause unknown, Meds- corticosteroids, tar preps, retinoids, photochemotherapy,and for severe--ultraviolet |
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Aspects of the disease of herpes zoster |
Viral- Herpes SimplexCaused by 2 types:1. HSV I- lips face 2. II- sexually transmitted. Virus lives in nerve ganglia and will exacerabate due to sunlight mestruation injury stress. Meds-- acyclovir for herpes lesions po,iv,top |
herpetic vesicles |
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Virus- Herpes Zoster: Shingles |
caused by varicella zoster (same virus that causes chickenpox). Lies dormant in the sensory dorsal ganglia years after the initial chickenpox infection it will get reactivated, most often when immunocompromised. Inflamm and painful vesicles, unilateral, Postthereptic neuralgia |
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What is the cause of athlete's foot
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Tinea Pedis- Athlete's Foot affects soles of feet between toes and toe nails. Fungal infection is Dermatophyte (Tinea) |
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herpes Simplex I and II |
1= lips face mouth II= std- physical contact kissing oral sex |
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Application of topical medications and therapeutic baths
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Therapeutic Baths- Purpose: soothe the skin lower the bacteria count. General rules for skin disorders: No soap for inflammatory skin conditions. No lotions or other skin products |
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Signs and Symptoms of a skin malignancy are? What are the risks? |
Skin is a common site for malignancy. Skin cancer is the most common form of all cancers. Nonmelanoma Skin Cancer- do not arise from melanin producing cells. Most caused by sun- UVR. May alter DNA or suppress T-Cell and B-Cell immunity. Most common malignant growth found in fair-skinned people. Skin pigmentation affects the development of nonmelanoma skin cancer. The more melanin in the skin (darker) the more protection from damaging UV rays. 2 types of Nonmelanoma Skin cancer1. Basal Cell Carcinoma- most common2. Squamous Cell carcinoma |
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Basal Cell Carcinoma |
Begins in the basal cell layer of the epidermis usually on sun-exposed areas. Slow-growing and rarely metastasize but can invade nearby areas. Can recur in same location after tx. Starts as smooth itchy pimple but as they grow, becomes shiny and pearly white or pink/skin colored |
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Squamous Cell Carcinoma |
Malignant tumor of the squamous epithelium of skin or mucous membranes. Exposed skin to UV rays. Much more aggressive than basal cell with faster growth rate and greater potential for metastasizing. Begins as firm flesh or red colored papule may be crusted and as grows, bleeds, ulcerates,and , painful. Area around nodule= undurated/hard |
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Melanoma |
AKA cutaneous or or malignant melanoma. Arises from melanocytes the cells that produce melanin. Incidence is increasing annually doubleld in past 3 yrs. Can metastasize when penetrate dermis and mingle with blood/lymph vessels. Precursor lesions are
Dysplastic nevi (atypical moles) during childhood and become abnormal after puberty
Congenital nevi (present at birth)
Lentigo maligna (tan or black patch on skin that lookslike a freckle but grows slowly becone mottled darkthick and nodular usually on side of face on older adult with excessive sun exposure |
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ABCDE Rule |
Assess suspicious lesions for:A- Assymmetry B- Border irregularity C- Color variation or dark black D- Diameter greater than 5 mm E- Evolution (history) |
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TREATMENT focused on removal of malignant tissue |
using Surgery Curetage electrodsiccation cryptherapy immunotherapy radiation biological |
scrapingburning off |
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DIAGNOSTICS for Skin cancer |
diagnosed by biopsy and microscopic examination of the tissue. Liver function test (LFT) is done to see if metastasized. CT scan of liver if abnormal. CXR. CBC for hematologic abnormalities. Chemistry for electrolytes. |
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PREVENTION
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Stay out of sun between 10 a.m. and 4 p.m. Wear hats sunglasses |
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CONTINUITY OF CARE
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Educate on prevention and early detection!!Teach on what changes to look for p. 1150. Color Size Shape appearance conisistency surrounding skin sensation |
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pruritus and treatment |
Puritis- subjective itching sensation that produces an urge to scratch. Underlying cause: insect bites animals plants fabrics metals meds allergies emotional distress
meds--antihistamines tranqilizers abx corticosteriods therapeautic baths ie cornstarch, baking soda ,colloidal |
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Macule
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Patch- flat nonpalpable change in skin color
ie- freckles measles petechiae
if in patches ie- mongolian spots port-winestains,, vitiligo, choasma |
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*Vitiligo |
abnormal patchy loss of melanin over face hands groin |
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*Petechiae |
small reddish-purple pinpoint spots over abd and buttocks. |
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Papule |
plaque-elevated solid palpable mass with circumscribed border
ie warts moles lichen planus |
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Nodules & tumors |
elevated solid hard/soft palpable mass extending deeper into the dermis thana papule Nodules-- small lipoma, squamous cell carcinoma, fibroma, intradermal nevi Tumors-- large lipoma, carcinoma, hemangioma. May irregular borders |
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Vesicle & bulla |
elevated fluid-filled round/oval shaped thin translucent walls circumscribed borders
Vesicles ie- herpes simplex/zoster, early chickenpx, poison ivy, small burn blister, Bullae-- contact dermatitis, friction blisters, large burn blisters |
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Pustule
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elevated pus-filled vesicle or bulla with circumscribed border. Acne, impetigo, carbuncles (large boils) |
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Cyst
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elevated encapsulate fluid-filled originating SQ/dermis |
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Atrophy
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translucent dry paper-like sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin (striae aged skin) |
wrinkles |
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Erosion
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wearing away of the superficial epidermis causing a moist shallow depression. They do not extend into the dermis so no scarring. (Stretch marks, ruptured vesicles) |
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Lichenification
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rough thickened hardened area of epidermis resulting fom chroic irritation such as scratching or rubbing. (Chronic dermatitis) |
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Scales
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shedding flakes of greasy keratinized skin tissue. Color may be white ie- dandruff dry skinn psoiasis excema |
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Crust
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dry blood serum or pus left on the skn surface when vesicles or pustules burst. Large crusts are called scabs. (Exzema impetigo herpes scab after abrasion |
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Ulcer
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deep irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. May bleed or leave scar. (Decubitus ulcers stasis ulcers, chancres) |
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Fissure
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linear crack with sharp edges extending into the dermis. Cracks in the corners of the mouth or in the hands |
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Scar
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flat irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or purple; Older ones may be silvery or white. (Healed surgical wound or injury healed acne) |
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Keloid
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elevated irregular darkened area of excess scar tissue caused by excessive collagen formation during healing. Extends beyond the site of original injury. Higher incidence in African Americans. (ear pearcing surgery) |
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Mycostatin
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Antifungal medication. Mycostatin- nystatin can be oral solution powder tab supp cream. Swish/swallow, take after meals to keep solution coated in mouth as long as possible/ |
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Acne cause and treatment |
Acne- disorder of the sebaceous glands. Glands produce sebum in response to direct hormonal stimulation by testicular androgens in men and adrenal and ovarian androgens in women.treatment-- based on type and severity. With comodones-- retin a benzyl peroxide. With inflamm= accutane, topical antibiotics. Tx months-lifetime |
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Types of acne |
Acne Vulgaris- adolescents and young to middle-aged. High fat diets chocolate have been disproved Acne rosacea
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Cellulitis
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Bacterial infection. Localized infection of the dermis and subcutaneous tissue. Can occur after a wound or skin ulcer or extension of furuncles and carbuncles. A substance called spreading factor or hyaluronidase breaks down fibrin network that normally localize infection. |
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Furuncles
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boils.an infection of the hair follicle. A group is called a carbuncle. Begins as folliculitis and spreads down hair shaft through wall of follicle and into dermis. Poor hygiene, trauma, excess moisture, dm. |
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Folliculitis |
most often caused by Staphylococcus Aureus. Inflammation pustules surrounded by erythema. Most often on scalp and extremities |
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causes of fungal infections |
Mycoses- Fungi are plantlike organisms that live in soil on animals tinea pedis/cruris candida albicans |
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Fungal infections - Dermatophyte |
(Tinea)-Tinea Pedis- athlete's foot affects soles of feet between toes and toenails. Tinea Cruris- jock itch |
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pediculosis
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Pediculosis (lice)- Parasitic infestation. Poor hygiene situations. Through contact with infecte person or objects or clothing. Parasites that ingest blood of the host.
Pediculosis corporis- infestation of body lice.Pediculosis captis- head licePediculosis pubis- pubic lice crabs. Intense itching with all. |
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Identify the description of all the burn depths, superficial---deep full-thickness |
(See chart 46-1 p. 1160!! P 15 of powerepoint!!)***First Degree burns- cause painful erythema and swelling. Second Degree burns- cause red painful blisters. Third Degree burns- white or blackened areas. |
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SUPERFICIAL BURNS (1st Degree) |
Epidermal layer with skin intact. Pink to red in appearance with pain and mild edema. Does not involve sweat glands oil glands or hair follicle. R/T sunburn uvlight minor flash injury ignition/explosion mild radiation. If large BSA=chills, ha,n,v |
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PARTIAL-THICKNESS BURNS (2nd Degree) |
Subdivided into SUPERFICIAL or DEEP. Involves the entire dermis and is bright red with blisters and moist glistening appearance. Mild to moderate edema pain r/t flash flame dilute chemical agent or hot surface/liquids |
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DEEP PARTIAL-THICKNESS BURNS |
involves the entire dermis plus hair follicle. Sebaceous and epidermal sweat glands remain intact. Red to white in color with moderate edema and pain > 21 days to heal. R/T hot liquids or solids flash flame direct intense radiant energy chemical agents. Skin pale waxy moist or dry. Large blisters decreased cap refill necrosis contractures. Possible scarring fx impariment |
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FULL-THICKNESS BURN (3rd Degree) |
involves all layers of the skin and may extend into the subcutaneous fat connective tissuemuscle and bone. appears pale waxy yellow brown mottled charred nonblanching red. edema leathery and firm. Weeks-mos to heal with skin grafts. Pain receptor s can be destroyed. |
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DEEP FULL-THICKNESS BURN (4th Degree) |
Deepest burn involving muscle and bone. Black in color with eschar. No pain or edema. Hard and firm and inelastic. Weeks and months to heal with skin grafts. R/T flames electricity |
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STAGE 1: EMERGENT OR RESUSCITATIVE
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Lasts from the onset of injury---- through successful fluid resuscitation. Estimating extent of burn first aid measures and implementing fluid rescusitation tx; s/s shock & resp distress; possible transport; #1 resp status! hob 30, airway/intubation, 02 flow face mask may need ventilator (death from burns usually due to pneumonia) s/s resp injury are face burns singed nasal facial hair rapid/shallow resp, coughing, increasing hoarseness, stridor, smokey breath, black sputum decreased 02 sats burning in throat chest restless anxiety confusion
fluid rescusitation-- npo, fluid replacement in all burns of 20 % or more tbsa. Weight must be obtained, calc from time of burn injury. coloids crystalloids blood/ blood products used.
Colloids-- plasma protiens albumin dextran gelatin.
Crystalloids- d5w 0.9%ns, 0.45% NS, LR. Admin through 2 large bore iv peripheral or central to maintain output 30-50ml/h. Lactated r is isotonic and amin iv due to closeness to extracell fluids. May require hemodynamic monitoring.
INITIATION OF FLUID RESCUSITATION SHOULD PRECEDE INITIAL WOUND CARE IN ADULTS. Iv fluid rescusitation is usually necessary in 2nd/3rd degree burns invol over 20% tbsa, older children with burns >15% or >tbsa See parkland formula. VS q h . Wound care Admin tetanus to prevent clostridium tetani in wound. Initial tx depends on protocol.Open method with antimicrobial tx & closed with covered dressings |
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Nursing priorities in stage 1: ndx |
Maintaining patent airway Fluid resuscitation pain
nursing diagnosis- risk ineffective airway, defecient fluid vol, risk ineffective tissue perfusion, |
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The Parkland Formula
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is used to guide initial fluid resuscitation during the 1st 24 hrs. 2 large-bore IV peripheral lines should be placed or preferably a CENTRAL LINE and LR SOLUTION. The formula calls for 4 mL/kg/TBSA burn of LR solution over the 1st 8 hours post burn the remaining half should be administered over the next 16 hrs. URINE OUTPUT is indicator of adjustments made in fluid infusion. After 24 hours, d5w for adult is infused and d5-1/2 ns for child. 30-50ml/h!!!! 3rd spacing= fluid dehydration risk/edema!! |
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STAGE 2 ACUTE STAGE |
Starts with diuresis and ends with closure of the burns. Treatments of hydrotherapy debridement excision and grafting of full-thickness wounds ASAP. Enteral (NG or PEG) and parenteral (TPN) feedings for caloric needs. Topical and systemic antimicrobial agents to prevent infection. NARCOTIC AGENTS for invasive procedures and control pain for debridement and physical therapy. Morpine diluadid fentanyl benzodiazepines as iv, patch, pca pump, po not as effective, very painful. Nursing interventions--- impaired skin integ r/t burn deficient fluid vol r/t shift in fluids, acute pain r/t burn, risk for infection, pain, imbal nutrition, powerlessness NUTRITION 4k-6k q d r/t excess protien breakdown, vit c & zink =healing, enternal via ng tube w/in 24h-48h to prevent hypermetabolism and improve nitrogen balance. Enternal feedings CONTRAIN in curlings ulcer, bowel obstr, feeding intol, pancreatitis, septic ileus-- tpn via subclavian cath VS freq & note changes pulse & bp, monitor i&o 30-50ml/h, weigh q d |
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STAGE 3: REHABILITATIVE STAGE |
Begins with wound closure and ends when the client returns to highest level of health. Prevention of contractures. Can take years. Biopsychosocial adjustment is focus. Resumption of work family |
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treatment for a burn including topical applications like Sulfamylon and Hydrotherapy |
Wound management: Monitor the appearance of burn wound. Normal burn healing is pink and shiny. Type of drainage/odor present. Monitor WBC and temperature for indications of infection. Use protective isolation and contact isolation if the client has an infection of the burn. Maintain ASEPTIC TO STERILE wound care and isolation technique to decrease risk for infection. Administer pain medications before wound care also try usig noninvasive methods to control pain. Change dressings as prescribed. Cleanse wound with N/S if on the face. May have HYDROTHERAPY to remove topical agents and debride the wound. |
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Open Wound Care
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Open to the air after debridement with topical agents applied. Wet soaks prior to applications. Apply extra warmth with blankets over cradle/heat lamp. |
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Mafenide acetate (Sulfamylon)
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is a synthetic antibiotic used to prevent infection to smaller areas. Caution with renal or pulmonary clients. Assess for allergic reaction. PAIN UPON APPLICATION. Apply 2-3x a day. |
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Silver nitrate or silver-coated dressings (Anticoat)
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Bacteriostatic agent used. Apply to gauze dressing q 2 hrs and change dressing BID. Assess for Na+ and Cl levels due to water absorption from the wound. Causes skin and dressing to turn black. |
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Silver Sulfadiazine or Silvaden
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Thick white cream applied to burns BID. Antimicrobial to prevent infections. Old cream must be removed first. Monitor WBC for leucopenia. Apply 1-2 x a day and completely cover. |
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PluroGel
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Topical antimicrobial agent. Bright yellow water-soluble gel similar to aloe vera. Burning sensation on application. Remove old cream first. |
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Closed Wound Care
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Antimicrobial agent applied and covered with gauze or nonadherent (Telfa) and wrapped with kerlix or kling. Usually BID. Wrap in distal-to-proximal manner. Fingers and toes separately. Be able to asses circulation. Wet dressings are soaked every 2 hours.
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Biologic and Biosynthetic Dressings
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Temporary material that adheres to the wound bed and promotes healing or prepares for a graft. Easy to apply and remove. Inexpensive. Elastic. Reduces pain. Bacterial barrier. Enhances healing.
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EXCERCISES
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Active and passive ROM excercises by PT in hydrotherapy and q 2 hrs. Early ambulation. Splints are used to immobilize body parts and prevent contractures. A contracture is a permanent shortening of connective tissue that develops during the healing process when the burn scar shrinks and becomes fixed and inelastic.
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What is the purpose of the pressure garment
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Tubular support bandages applied post graft 5-7 days to apply uniform pressure to prevent or reduce hypertrophic scarring. Worn 6-12 months post-graft.
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What is the rule of nines
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RAPID method of estimating the extent of partial and full-thickness burns. Performed during pre-hospital and emergency care. Head trunk arms legs perinem are assigned a percentage. tbsa |
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Nursing care for the client with a burn
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comfort and pain
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Signs and symptoms of complications of a burn
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S&S of a burn infection: Strong odor to the wound A very wet dressing or sloughing of the graft, color change to dark red/brown, redness around edges extending to nonburned skin texture change purulent drainage
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What is debridement
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Debridement- the process of removing dead tissue from a wound. Eschar is a hard crust that forms over the burn wound. Burn wounds must be cleaned and debrided of nerotic tissue and blisters to promote healing and prevent prolonged inflammation. Usually occurs 1 week after the burn. The wound is cleansed with an antimicrobial soap such as Hibiclens. Dial or Shur-Clens for the face due to toxicity to the eyes with Hibiclens. Hair is shaved. IV narcotics are administered before debridement to control pain. |
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Mechanical Debridement
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performed during hydrotherapy. Loose necrotic tissue is removed in water with gentle rubbing on the area. Shower spray table or emersion in water. |
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Enzymatic Debridement
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Elase ointment and Santyl ointment. Topical agent to dissolve and remove necrotic tissue. Thin layer is applied and covered with one layer of fine mesh gauze. Topical antimicrobial agent is then applied and covered with a bulky wet dressing and immobilized with expandable mesh gauze. |
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Surgical Debridement
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Process of excising tissue from the burn wound to the level of viable tissue. Eletrocautery or use of a dermatome to remove the damaged skin. |
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What is the complication of an electrical burn
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Electrical burn- is related to type duration of current amt of voltage. Causes impaired blood flow secondary to blood coag at burn site. heart stop arrythmia |
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What is the Curling ulcer and how is it treated |
Curling's Ulcer- can develop in stomach or duodenum in 24 hrs due to impairment of stomach mucosa. Treat with histamine receptor medications famotidine/Pepcid(cimetidine/Tagamet zantac protonix. Pain hemataemesis +guiac stool and paralytic ileus from lack of intestinal motility resulting in gastric distention & n,v. |
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What is the Escharotomy |
Escharotomy- performed with a scalpel or electrocautery to open skin. A sterile incision is made longitudinally along the extremity or trunk to prevent constriction or impaired circulation.ASSESS FOR COMPARTMENT SYNDROME! 6 P's of compartment syndrome: Pain Pallor performed with a scalpel or electrocautery to open skin. A sterile incision is made longitudinally along the extremity or trunk to prevent constriction or impaired circulation.ASSESS FOR COMPARTMENT SYNDROME! 6 P's of compartment syndrome: Pain Pallor Pulselessness |
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How does the Parkland Formula work
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The Parkland Formula is used to guide initial fluid resuscitation during the 1st 24 hrs. 2 large-bore IV peripheral lines should be placed or preferably a CENTRAL LINE and LR SOLUTION. The formula calls for 4 mL/kg/TBSA burn of LR solution over the 1st 8 hours post burn the remaining half should be administered over the next 16 hrs. URINE OUTPUT is indicator of adjustments made in fluid infusion. After 24 hours |
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What happens to the fluids/electrolytes following a burn during the different stages? |
(see powerpoints for burn pathophysiology |
Involves all systems of body.) During the first 48 hours after a burn--capillary permeability is increasing allowing fluids to shift from plasma to the interstitial spaces. The fluid is high in sodium causing a decrease in serum sodium or hyponatremia (135-145 mEq/L). Potassium leaks from the cells into the plasma hyperkalemia (3.5-5.0 mEq/L)Fluid loss via evaporation occurs and must be replaced. Larger the burn |
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Urine output should be used as a measure of renal perfusion and to assess fluid balance. |
In adults a urine output of 30-50 mL/hr and a child 0.5/kg/h should be maintained. Pts with significant burns should have a FOLEY CATHETER inserted in order to monitor urine output closely with a UROMETER. |
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GRAFTING |
Autografting: Permanent skin coverage of the wound. Performed early. Skin is removed from a donor site and applied to the burn wound from the client. Area is immobilized and assessed for rejection and infection. Care with donor site to prevent infection. Cover the site. Cultured epithelial autografting- skin cells are removed from unburned site minced |
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Nursing Interventions for Skin Grafting |
Assess graft and donor sites for complications like rejection and infection. Donor site covered with film dressing. No pressure on donor site. Pain control due to donor site pain. Apply pressure dressings to grafts and worn for 23 hours a day. Continue to keep client informed and teach the client about the aspects of their care. Make the environment easy for access of items and safe. Tubular support bandages applied post graft 5-7 days to apply uniform pressure to prevent or reduce hypertrophic scarring. Worn 6-12 months post-graft. |
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Candida albicans |
yeast like fungus found on mucous membranes ie skin vag gi tract. Likes moisture warmth altered skin integ systemic abx pregnancy birth control poor nutriion immunodeficiency dm |
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Nonmelanoma skin cancer |
do not arise from melanin producing celsl. Most caused by SUN- uvr. May alter dna or suppress t & b cell immunity. Most common malignant growth found in the fair skinned. More melanin= more protection Ie: basal cell & squamous cell carcinoma |
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