Transcript Chapter 34

Chapter 50
Skin Disorders
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Learning Objectives
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Describe the structure and functions of the skin.
List the components of the nursing assessment of the
skin.
Define terms used to describe the skin and skin lesions.
Explain the tests and procedures used to diagnose skin
disorders.
Explain the nurse’s responsibilities regarding the tests
and procedures for diagnosing skin disorders.
Explain the therapeutic benefits and nursing considerations
for patients who receive dressings, soaks and wet wraps,
phototherapy, and drug therapy for skin problems.
Describe the pathophysiology, signs and symptoms, diagnostic
tests, and medical treatment for selected skin disorders.
Assist in developing a nursing care plan for the patient
with a skin disorder.
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Anatomy and Physiology
of the Skin
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Definition
• The skin is an organ that covers the body
surface
• Two distinct layers
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Epidermis
• Outermost layer that covers the dermis
• Continually produces new cells to replace
those at the surface
• Produce melanin, a dark pigment, that helps
determine the color of the skin
• Strong ultraviolet light, such as in sunlight,
stimulates the production of melanin
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Dermis
• Strong connective tissue that contains nerve
endings, sweat glands, hair roots
• Well supplied with blood vessels, causing the
skin to redden when surface vessels are
dilated
• Subcutaneous tissue lies beneath the dermis
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Figure 50-1
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Appendages
• Hair, nails, and sebaceous glands
• Hair root located in tube in dermis called a hair
follicle
• Arrector muscles located around hair follicles
contract, causing hairs to stand erect and
gooseflesh skin
• Sebaceous glands secrete oily substance: sebum
• Sweat glands, in most parts of the skin, secrete
through skin surface water that contains salts,
ammonia, amino acids, lactic acid, ascorbic acid,
uric acid, and urea
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Functions
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Protection
Temperature regulation
Secretions
Sensation
Synthesis of vitamin D
Blood reservoir
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Age-Related Changes
• Wrinkling a result of thinning skin layers and
degeneration of elastin fibers
• Sweat glands decrease, although production
changes little until advanced age
• Production of sebum decreases, becoming
apparent earlier in women than in men
• Dryness and pruritus are common
• Skin pales because the number of cells that
produce melanin decreases
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Age-Related Changes
• Skin lesions are more common
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Lentigines
Senile purpura
Senile angiomas
Seborrheic keratoses
Acrochordons
• By age 50, nearly half have some gray hair
• Men begin to lose hair from the scalp in their
40s; by their 80s many almost bald
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Age-Related Changes
• Scalp hair thins in women as well but usually
less obvious
• Increase in facial hair in both sexes
• Men may have increased hair in the nares,
eyebrows, or helix of the ear
• Nails flatten; become dry, brittle, and discolored
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Figure 50-2
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Health History
• Chief complaint and history of present illness
• Discomfort, pruritus, color changes, lesions, hair
loss, or abnormal hair growth
• Onset of condition/precipitating or alleviating factors
• Past medical history
• Previously diagnosed skin diseases or problems,
current and recent medications, and allergies
• Diabetes mellitus, cancer, kidney failure, thyroid
disease, liver disease, and anemia
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Health History
• Review of systems
• Change in skin color or pigmentation, change in a
mole, sores slow to heal, itching, dryness or
scaliness, excessive bruising, rashes, lesions, hair
loss, unusual hair growth, changes in nails
• Functional assessment
• Past and present occupations, exposure to
chemicals or other irritants, skin care habits, sun
exposure
• Recent changes in the work or living environment
• Current stresses and sources of anxiety
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Physical Assessment
• Skin color and variations in pigmentation
• Document dilated blood vessels and angiomas
• Nevi (moles) inspected for irregularities in
shape, pigmentation, and ulcerations or
changes in surrounding skin
• If a rash, location, distribution, and
characteristics. If any drainage, the color,
amount, and odor are noted
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Figure 50-3
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Physical Assessment
• Palpate skin for temperature, moisture, texture,
thickness, edema, mobility, and turgor
• Mobility and turgor
• Hair color, distribution, oiliness, and texture.
The scalp is inspected for scaliness,
infestations, and lesions
• Shape/contour of the fingernails and toenails
• Color of the nail bed
• Capillary refill checked by applying pressure to
the nail to cause blanching and then releasing
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Figure 50-4
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Diagnostic Tests and Procedures
• Microscopic examination of skin specimens
• Potassium hydroxide (KOH) examination
• Tzanck smear
• Scabies scraping
• Wood’s light examination
• Patch testing for allergy
• Biopsy
• Shave biopsy
• Punch biopsy
• Surgical excision
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Therapeutic Measures
• Dressings
• Protect wounds; retain surface moisture
• Types: wet, dry, absorptive, and occlusive
• Negative pressure wound therapy
• Reduce healing time of traumatic wounds, dehisced
surgical wounds, pressure and chronic ulcers
• Soaks and wet wraps
• Soothe, soften, and remove crusts, debris, and
necrotic tissue
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Therapeutic Measures
• Phototherapy
• Ultraviolet light in combination with photosensitive
drugs promotes shedding of the epidermis
• Drug therapy
• Topical drugs: keratolytics, antipruritics, emollients,
lubricants, sunscreens, tars, anti-infectives,
glucocorticoids, antimetabolites, antihistamines,
antiseborrheic agents, and vitamin A derivatives
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Disorders of the Skin
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Pruritus
• Etiology and risk factors
• Triggered by touch, temperature changes,
emotional stress, and chemical, mechanical, and
electrical stimuli
• Prominent symptom of psoriasis, dermatitis, eczema,
insect bites
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Pruritus
• Medical treatment
• Stress management and avoidance of known
irritants, sudden temperature changes, and alcohol,
tea, and coffee
• Lubricants in the bathwater and emollients applied
after bathing also may help
• Medications include corticosteroids, antihistamines,
and local anesthetics
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Pruritus
• Assessment
• Collect data about symptoms that may help
determine the cause
• The history of the current illness is important
because pruritus may be just one symptom of a
condition that requires attention
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Pruritus
• Interventions
• Lubricants/emollients; adding oils to bathwater
• Advise to avoid bathing in very hot water
• Administer medications or instruct patient in their
use
• Inspect skin daily to determine effects of treatment
• Explain possible causes of pruritus and encourage
the patient to avoid them
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Atopic Dermatitis (Eczema)
• Pathophysiology
• Acute stage: red, oozing, crusty rash and intense
pruritus
• Subacute stage: redness, excoriations, and scaling
plaques or pustules. Fine scales may give skin a
silvery appearance
• Chronic stage: the skin becomes dry, thickened,
scaly, and brownish gray
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Atopic Dermatitis (Eczema)
• Etiology and risk factors
• Personal or family history of asthma, hay fever,
eczema, or food allergies
• People with atopic dermatitis have an immune
dysfunction, but it is not known whether that
dysfunction is a cause or an effect of the disorder
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Figure 50-6
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Atopic Dermatitis (Eczema)
• Medical diagnosis
• Health history and physical examination
• Skin biopsy, serum immunoglobulin E levels, and
cultures; allergy tests
• Medical treatment
• Topical corticosteroids; systemic antihistamines
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Atopic Dermatitis (Eczema)
• Assessment
• Allergies, bathing practices, and current medications
• Interventions
• Impaired Skin Integrity
• Risk for Infection
• Disturbed Body Image
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Seborrheic Dermatitis
• Pathophysiology
• Chronic inflammatory disease of the skin
• Affects scalp, eyebrows, eyelids, lips, ears, sternal
area, axillae, umbilicus, groin, gluteal crease, and
under the breasts
• Areas affected by this condition may have fine,
powdery scales, thick crusts, or oily patches
• Scales may be white, yellowish, or reddish
• Pruritus is common
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Seborrheic Dermatitis
• Etiology and risk factors
• The cause is unknown
• May be an inflammatory reaction to infection with
the yeast Malassezia
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Seborrheic Dermatitis
• Medical diagnosis
• Health history and physical examination
• Medical treatment
• Topical ketoconazole (Nizoral), sometimes with
topical corticosteroids
• Shampoos that contain selenium sulfide (Selsun),
ketoconazole, tar, zinc pyrithionate, salicylic acid, or
resorcin
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Seborrheic Dermatitis
• Assessment
• Inspect and describe the affected areas
• Interventions
• Explain the condition and reinforce the physician’s
instructions for treatment
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Psoriasis
• Pathophysiology
• Abnormal proliferation of skin cells
• Classic sign: bright red lesions that may be covered
with silvery scales
• Etiology and risk factors
• Caused by rapid proliferation of epidermal cells
• Usually chronic with cycles of exacerbations and
remissions
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Psoriasis
• Medical diagnosis
• Health history and physical examination
• Medical treatment
• No cure; usually treated with topical medications:
corticosteroids, tazarotene, Estar (coal tar), and
vitamin D derivatives
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Figure 50-7
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Psoriasis
• Assessment
• Describe symptoms and treatments
• Inspect affected areas for lesions and scales
• Document joint pain or stiffness because the
condition may cause arthritis
• Interventions
• Ineffective Therapeutic Regimen Management
• Disturbed Body Image
• Social Isolation
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Intertrigo
• Pathophysiology
• Inflammation where two skin surfaces touch: axillae,
abdominal skinfolds, and under the breasts
• The affected area is usually red and “weeping” with
clear margins; may be surrounded by vesicles and
pustules
• Etiology and risk factors
• Results from heat, friction, and moisture between
touching surfaces
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Intertrigo
• Medical diagnosis and treatment
• Based on site/appearance of inflamed skin
• If the skin not broken, wash with water twice daily;
rinse and pat dry; soft gauze used to separate layer
of tissue and absorb moisture
• For severe inflammation or fungal infection: topical
corticosteroid or antifungal agent
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Intertrigo
• Assessment
• Complaints of pain, irritation, or redness in body
folds
• Inspect susceptible areas daily
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Intertrigo
• Interventions
• Areas where skin surfaces are in contact must be kept clean
and dry
• Apply topical medications as ordered
• Report increasing redness and tenderness, fever, and broken
skin to the physician
• Encourage women with pendulous breasts to wear a soft,
supportive bra
• If incontinence has contributed to perineal intertrigo, position
patient with legs apart to allow moisture to evaporate
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Fungal Infections
• Pathophysiology
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Tinea pedis (athlete’s foot)
Tinea manus (hand)
Tinea cruris (groin)
Tinea capitis (scalp)
Tinea corporis (body)
Tinea barbae (beard)
Candidiasis: affects skin, mouth, vagina,
gastrointestinal tract, and lungs
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Fungal Infections
• Etiology and risk factors
• Spread through direct contact or by inanimate objects
• Lesions may be scaly patches with raised borders
• Pruritus common symptom
• Medical diagnosis
• Confirmed by microscopic examination of skin
scrapings
• Medical treatment
• Fungal: treated with antifungal powders and creams
• Oral candidiasis: treated with clotrimazole troches, nystatin
mouthwash or lozenges, oral amphotericin B
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Figure 50-8
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Fungal Infections
• Assessment
• Conditions that might make a person susceptible to
fungal infections
• Inspect the skin and mucous membranes for lesions
• Interventions
• Disturbed Body Image
• Altered Oral Mucous Membrane
• Risk for Injury
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Acne
• Pathophysiology
• Affects the hair follicles and sebaceous glands
• Comedones (whiteheads, blackheads), pustules, cysts
• Often develop on the face, neck, and upper trunk
• Etiology and risk factors
• Androgenic hormones cause increased sebum production;
bacteria proliferate, causing sebaceous follicles to become
blocked and inflamed
• Medical diagnosis
• Health history and physical examination findings
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Acne
• Medical treatment
• Topical medications: antibiotics, keratolytics such as
benzoyl peroxide, topical vitamin A preparations
• Oral antibiotics given over several months
• Nonpharmacologic treatment: comedo extraction or
cryotherapy
• Dermabrasion to reduce scarring
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Acne
• Assessment
• Document any treatments being used
• Inspect skin to determine extent and severity
• Interventions
• Disturbed Body Image
• Ineffective Therapeutic Regimen Management
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Herpes Simplex
• Etiology and risk factors
• Viral infection begins with itching and burning and progresses
to vesicles that rupture and form crusts
• Nose, lips, cheeks, ears, genitalia most often affected
• Oral lesions called cold sores or fever blisters
• Infections on the face and upper body usually caused by HSV1; genital infections by HSV-2
• Medical diagnosis
• Laboratory studies of exudate from a lesion and blood studies
to detect specific antibodies
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Figure 50-9
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Herpes Simplex
• Assessment
• Describe the development of the herpetic lesions
• Sexual contacts documented so that they can be advised of
the need for medical evaluation
• Inspect the lesions
• Interventions
• Acute Pain
• Ineffective Coping
• Ineffective Therapeutic Regimen Management
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Herpes Zoster
• Etiology and risk factors
• Commonly called shingles
• Varicella-zoster virus; also causes chickenpox
• Symptoms: pain, itching, and heightened sensitivity along a
nerve pathway, followed by the formation of vesicles in the
area
• When the skin is affected, crusts form
• Older adults especially susceptible to complications
• Immunosuppressed at greater risk for herpes zoster infections;
may have serious systemic complications
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Figure 50-10
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Herpes Zoster
• Medical diagnosis
• Health history and physical examination findings
• Tzanck smear or viral culture of material from a lesion
• Medical treatment
• Antiviral agents: acyclovir, famciclovir, valacyclovir, and
foscarnet
• Wet dressings soaked in Burow’s solution
• Pain may be treated with analgesics and sedatives
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Herpes Zoster
• Assessment
• Conditions or treatments that might cause the
patient to have a reduced immune response
• Distribution and appearance of the lesions
• Interventions
• Impaired Skin Integrity
• Acute Pain
• Ineffective Coping
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Necrotizing Fasciitis
• Infection of deep fascial structures under the skin
• Aerobic and anaerobic organisms: Streptococcus,
Staphylococcus, Peptostreptococcus, Bacteroides, and
Clostridium species
• Organisms excrete enzymes that destroy blood
vessels that supply the affected area
• Deprived of blood flow, tissue necrosis occurs
• Treatment involves extensive débridement, intravenous
and topical antibiotics, and eventual skin grafting
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Infestations
• Lice
• Scabies
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Figure 50-12
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Pemphigus
• Chronic autoimmune condition: bullae (blisters) develop on the
face, back, chest, groin, and umbilicus
• Blisters rupture easily, releasing a foul-smelling drainage
• Potassium permanganate baths, Domeboro solution, and oatmeal
products soothe the affected areas, reduce odor, and decrease
the risk of infection
• Treatments: corticosteroids, other immunosuppressants, and oral
or topical antibiotics
• Patients with extensive skin loss require the same care as burn
patients
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Actinic Keratosis
• Precancerous lesions most often found on the face,
neck, forearms, and backs of the hands—all areas
exposed to sunlight
• May become malignant if not treated
• Most common among older white adults
• Appear as papules or plaques of irregular shape
• The hard scale on the lesion may shed and reappear
• Treatments include drug therapy, cryotherapy,
electrodesiccation, and surgical excision
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Nonmelanoma Skin Cancer
• Basal cell carcinoma
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Painless, nodular lesions; pearly appearance
Related to sun exposure
Grow slowly and rarely metastasize
Treated with surgical excision, Mohs’ micrographic
excision, electrodesiccation and curettage,
cryotherapy, radiation, or drugs that are applied
topically or injected into the lesion
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Nonmelanoma Skin Cancer
• Squamous cell carcinoma
• Scaly ulcers or raised lesions
• Develop on sun-exposed areas including the lips,
and in the mouth
• Caused by overuse of tobacco and alcohol
• Grow rapidly and metastasize
• Treatment may include surgical excision,
cryotherapy, and radiation therapy
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Figure 50-13A-C
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Melanoma
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Arises from pigment-producing cells in the skin
Most serious form of skin cancer; fatal if it metastasizes
Found anywhere on the body
Irregular borders and uneven coloration; many are dark,
but some are light. Begin as tan macule that enlarges
• Removed surgically; a wide area around a melanoma
is usually excised
• Chemotherapy and immunotherapy also may be
employed
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Figure 50-13D
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Cutaneous T-Cell Lymphoma
• Migration of malignant T cells to the skin
• Mycosis fungoides and Sézary syndrome
• May resemble eczema, with macular lesions appearing
on areas protected from the sun
• Tumors form, enlarge, spread to distant sites
• When confined to the skin, this type of lymphoma can
be cured with topical chemotherapy, systemic
psoralens with UVA, and/or superficial radiotherapy
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Kaposi’s Sarcoma
• Malignancy of the blood vessels
• Red, blue, purple macules with pain, itching, swelling
• Lesions appear first on the legs and then on the upper body, face,
and mouth
• Enlarge to form large plaques that may drain
• In patients with HIV but not confined to this group
• Local lesions excised or injected with intralesional chemotherapy
• Systemic lesions are treated with chemotherapy, immune therapy,
and radiotherapy
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Disorders of the Nails
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Infections
• Usually indicated by redness, swelling, and
pain around the margin of the nail
• Treated with warm soaks and topical or
systemic anti-infectives
• Incision and drainage may be necessary
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Ingrown Toenail
• Painful inflammation at distal corner of nail
• Caused by trimming nail too short at the
corners or wearing shoes that are too tight
• Ingrown nail should be protected from pressure
as it grows out
• Warm soaks may be soothing
• Surgical excision of ingrown portion of nail
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Care of the Patient with a Nail
Disorder
• Assessment
• Health history should document the diagnoses of
diabetes mellitus or peripheral vascular disease
• In the physical examination, inspect the nails for
redness, swelling, or pain
• Inspect extremities for lesions and abnormal color,
and palpate for warmth and peripheral pulses
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Care of the Patient with a Nail
Disorder
• Interventions
• Teach patients how to trim their nails correctly and
the importance of properly fitting shoes
• Toenails should be cut straight across and even with
the end of the toe
• If patient cannot care for the feet adequately, refer
to a podiatrist
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Burns
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Definition of Burns
• Tissue injuries caused by heat
• Depending on source of injury, burn is
described as thermal (flame, flash, scalding
liquids, hot objects), chemical, electrical,
radiation, or inhalation
• Leading cause of accidental death despite
improved survival rates attributed to advances
in the care of burn patients
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Classification
• Burn size
• Rule of nines
• Lund and Browder method
• Burn depth
• Superficial burn (first degree)
• Affect only the epidermis
• Superficial or deep partial-thickness burn (second degree)
• Affects the epidermis and the dermis
• Full-thickness burns (third degree, fourth degree)
• Extend into even deeper tissue layers
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Figure 50-15
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Figure 50-16
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Figure 50-17
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Burn Severity
• American Burn Association criteria
• Burn size: 25% or more body surface area for
people younger than 40 years; 20% or more body
surface area for older than 40 years
• Disfiguring or disabling injuries to the face, eyes,
ears, hands, feet, or perineum
• High-voltage electrical burn injury
• Inhalation injury
• Major trauma in addition to the burn
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Pathophysiology of Burn Injury
• Local effects
• Tissue releases chemicals that cause increased capillary permeability,
which permits plasma to leak into the tissues
• Injury to cell membranes permits excess sodium to enter cell and
potassium to escape into the extracellular compartment
• These shifts cause local edema and decrease in cardiac output
• Fluid evaporates through the wound surface, further contributing to
the declining blood volume
• 18 to 36 hours after a burn injury, capillary permeability begins to
normalize and reabsorption of edema fluid begins
• Cardiac output returns to normal and then increases to meet
increased metabolic demands
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Pathophysiology of Burn Injury
• Systemic effects
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Fluid balance
Gastrointestinal function
Immune system
Respiratory system
Myocardial depression
Psychological effects
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Stages of Burn Injury
• Emergent: begins with the injury and ends
when fluid shifts have stabilized
• Acute: begins with fluid stabilization and ends
when all but 10% of burn wounds are closed or
when all wounds are closed
• Rehabilitation: lasts as long as efforts continue
to promote improvement
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Medical Treatment: Emergent Stage
• Assess airway, breathing, and circulation and then
determine whether the patient has injuries in addition
to the burn
• If inhalation injury, oxygen therapy is started
• May require intubation if airway is compromised
• IV lines established to begin fluid resuscitation and to
provide emergency vascular access
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Medical Treatment: Emergent Stage
• Indwelling urinary catheter and a nasogastric
tube usually inserted
• Blood drawn for baseline lab studies
• Tetanus prophylaxis may be administered
• Pain assessed and analgesics are ordered
• Wound is cleaned, débrided, and inspected
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Medical Treatment: Emergent Stage
• Patient with serious burns is transferred to a burn specialty care
unit or a critical care unit
• IV essential during the first few days of burn treatment
• Volume based on patient’s weight and extent of injury
• First 24 hours, IV fluids may consist of various combinations of
electrolyte, colloid, and dextrose solutions
• Second 24 hours, volume decreased based on urine output
• Fluids then different combinations of electrolyte, colloid, and dextrose
solutions
• Some formulas omit electrolyte solutions in the second 24 hours
• Antibiotic therapy and surgical procedures
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Wound Care
• Open method: topical antimicrobials but no
dressings
• Closed care: topical medications covered by
dressings
• Topical medications: silver sulfadiazine
(Silvadene) and mafenide acetate (Sulfamylon)
• Tetanus booster given if patient has not been
immunized within the past 5 years
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Wound Care
• For clean partial-thickness wounds that will
heal without grafting, temporary wound
coverings
• Amniotic membranes, grafts from cadavers or pigs,
and a number of synthetic materials
• Graft sites also treated with negative pressure
wound therapy
• Donor sites treated with fine-mesh gauze and
synthetic and biosynthetic products
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Wound Care
• Débridement
• Removal of debris and necrotic tissue from a wound
• By scissors, forceps, surgical excision, or enzymes
• Skin grafting
• Autograft: the patient’s own skin
• Split-thickness or a full-thickness graft
• Scarring
• Can be reduced with pressure dressings in the early stages of
care, followed by custom-fitted garments that apply continuous
pressure
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Figure 50-18
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Care of the Patient with Burn Injury
• Health history
•
•
•
•
Circumstances surrounding the burn injury
Chronic diseases, surgeries, or hospitalizations
Medications and allergies
Family history even though not specific to burn injuries; it may
alert the staff to other problems
• Review of systems detects current problems
• Habits and lifestyle, roles and responsibilities, stressors, and
coping strategies
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Care of the Patient with Burn Injury
• Physical examination
•
•
•
•
•
•
•
•
•
Vital signs
Inspect for burn wounds and other lesions
Wound color and the presence of eschar
Palpate intact skin for temperature and turgor
Chest expansion observed, and the lungs auscultated for
wheezing, stridor, or atelectasis
Apical pulse be auscultated for rate and rhythm
Abdomen assessed: active bowel sounds/distention
Extremities are inspected for injury and deformity
ROM assessment is delayed if extremity immobilized
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Care of the Patient with Burn Injury
• Interventions
•
•
•
•
•
•
•
•
•
Decreased Cardiac Output
Fluid Volume Excess
Acute Pain
Risk for Infection
Hypothermia
Risk for Imbalanced Nutrition: Less Than Body Requirements
Impaired Physical Mobility
Ineffective Coping
Ineffective Family Coping
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Conditions Treated with
Plastic Surgery
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Aesthetic Surgery
• Alters a body feature that is structurally normal
but perceived by the patient as unattractive
• Examples: rhytidectomy, blepharoplasty, chin
implants, rhinoplasty, abdominoplasty, breast
augmentation, and breast reduction
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Reconstructive Surgery
• Repair disfiguring scars, restore body contours
after radical surgery like mastectomy, eliminate
benign lesions such as birthmarks, restore
features damaged by trauma or disease, and
correct developmental defects
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Preoperative Nursing Care
• Assessment: health history
• Patient’s description of plastic surgery and what he or she
expects the procedure to accomplish. Past medical history
may elicit conditions that might affect wound healing
• Review of systems: surgical area receives special attention
• Functional assessment: patient’s lifestyle and usual activities
• Interventions
• Anxiety
• Deficient Knowledge
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Postoperative Nursing Care
• Assessment
• Vital signs and level of consciousness
• Inspect dressings for drainage or bleeding, but do
not remove them without specific orders
• Observe flaps and grafts for color and evidence of
fluid accumulation, and palpate for warmth
• Inspect and measure drain contents each shift
• Fluid should lighten from sanguineous (red) to
serosanguineous (pink) to serous (pale yellow)
• Patient’s comfort level
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Postoperative Nursing Care
•
•
•
•
•
•
Acute Pain
Risk for Infection
Risk for Injury
Risk for Deficient Fluid Volume
Disturbed Body Image
Ineffective Therapeutic Regimen Management
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