Management of Client With Integumentary Disorders

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.

Documents

Management of Client With Integumentary Disorders