INTEGUMENTARY

SYSTEM
Ma. Victoria J. Recinto, RN, USRN
University of the Philippines-Manila
Philippine General Hospital

ANATOMY: SKIN
Largest

sensory organ of the

body
Surface area: 15-20 square
feet, wt: 9 lbs
Layers: Epidermis, Dermis,
Hypodermis (SQ fat)

ANATOMY: SKIN

ANATOMY: SKIN
Epidermal appendages: nails, hair,
glands (sebaceous & sweat)
N bacterial flora: Pseudomonas,
Staphylococcus (Gram positive &
negative), Streptococcus
pH of 4.2-5.6 halts bacterial growth

ANATOMY: SKIN

PHYSIOLOGY: SKIN
1st line of defense against
infections
Protects underlying tissues, organs
Receives stimuli, detects touch,
pressure, pain and T, relays info to
CNS
Maintains N body T

PHYSIOLOGY: SKIN
Excretes salt, water and organic
wastes
Prevents excessive water loss
Synthesizes Vit. D that converts
calcitriol needed for Ca
metabolism
Stores nutrients

DIAGNOSTIC TESTS:
SKIN BIOPSY
For

histopathologic study
Include punch, excisional, incisional & shave
Obtain informed consent, cleanse site as
ordered
Send sample to pathology lab for analysis
Use aseptic technique in dressing site, keep
the dressing for at least 8hrs, then clean OD
& use antibiotic ointment as ordered

DIAGNOSTIC TESTS:
SKIN CULTURES
Noninvasive procedure
Sample is obtained using sterile
applicator
Viral culture is placed immediately
on ice
Obtain samples before starting
antibiotic therapy

DIAGNOSTIC TESTS:
WOODS LIGHT EXAM
Skin

is viewed under UV light

through a Woods glass to
identify superficial skin infection
Darken room before the exam

DIAGNOSTIC TESTS:
SKIN TESTING
Administration

of an allergen to the
surface of the skin or into the dermis (via
scratch, patch or ID techniques)
D/C systemic corticosteroids or
antihistamine tx 5d before the test
Obtain informed consent
Have resuscitation equipment available
s/p scratch test, it may induce
anaphylactic reaction

DIAGNOSTIC TESTS:
SKIN TESTING
Keep

site area dry

If patch test was done, avoid activities that
may produce sweating (if patch loosens or
falls off, it should not be reapplied)
Record the site, date & time of the test &
the follow-up site reading
WOF erythema, vesicles, edema &
induration

RISK FACTORS:
SKIN DISORDERS
Exposure

to
Chemicals, pollutants, radiation, sun
Improper hygiene
Cosmetics & harsh soaps
Long-term corticosteroids & anticoagulants
Nutritional deficiencies
Emotional stress
Infection
Aging

SKIN CANCER
Malignant

lesion of the skin,

may or may not metastasize
Causes: chronic friction,
irritation & UV rays
Dx: skin bx (+) for CA cells

SKIN CANCER
Types
Basal

cell: most common, in epidermis

Squamous cell: common among
whites, tumor of epidermal
keratinocytes, mets to lymph nodes
Malignant melanoma: CA of
melanocytes, mets to brain, lungs,
bone, liver & skin, fatal

SKIN CANCER
Appearance
Waxy nodule
Irregular, circular, bordered lesion
with hues of tan, black or blue
Small, red, nodular lesion
Oozing, bleeding, crusting lesion

SKIN CANCER: Nursing

Interventions
Monitor

lesions that do not heal or that change

characteristics
Remove moles or lesions subject to chronic
irritation
Avoid contact with chemical irritants
Wear layered clothing, apply sunscreens when
outdoors
Avoid sun exposure between 11am-3pm
Assist with surgical excision of the lesion as
prescribed

CONTACT DERMATITIS
Inflammatory

reaction after contact with a

specific antigen
Assessment
Pruritus
Edema
Erythema at contact site
Infection
Vesicles with drainage

CONTACT DERMATITIS:
Nursing Interventions

extremity to edema
Apply cool, wet dressings & TSB
Maintain cool envt
Protect area from trauma, avoid scratching &
rubbing
Assist with skin testing as ordered to determine
allergen
Avoid harsh soap, heating pads or blankets
Administer antibiotics, antipruritic, antihistamine &
corticosteroids as ordered

POISON IVY, OAK & SUMAC

Dermatitis

from contact with urushiol of these

plants
S/S: papulovesicular lesions, severe itching
Cleanse sin with plant oils
Apply cool, wet dressings with Burows solution
as ordered to itching
Apply lotion or topical corticosteroid as ordereds
Administer oral corticosteroids as ordered for
severe reaction

LYME DISEASE
An

infection
caused by
spirochete
Borrelia
burgdorferi from
a tick (in wooded
area, survives
by attaching to
the host) bite

LYME DISEASE: Assessment

1st stage
S/Sx occurs days to mos. following the tick bite
A small red pimple develops, spreads into a ring shaped
rash
Rash may be large or small or none at all
Flulike Sxs: HA, stiff neck, muscle aches, fatigue
2nd stage
Joint pains
Neurological & cardiac Cx
3rd stage
Large joint pains then progresses

LYME DISEASE: Assessment

LYME DISEASE:
Nursing Interventions
Gently remove the tick with
tweezers, wash skin with antiseptic,
dispose the tick by flushing it down
the toilet
Get a blood test 4-6 wks after the
bite to detect presence of disease
Administer antibiotic if dx confirmed

LYME DISEASE:
Nursing Interventions
Avoid wooded grassy areas esp. in
the summer mos.
Wear long-sleeved tops, long pants,
closed shoes & hats while outside
Spray the body with tick repellent
before going outside
Examine body when returning inside

ERYSIPELAS & CELLULITIS

Erysipelas: acute superficial, rapidly
spreading inflammation of dermis &
lymphatics caused by GABS (via
abrasion, bite, trauma or wound)
Cellulitis: skin infection of dermis &
SQ caused by Streptococcus
pyogenes

ERYSIPELAS & CELLULITIS

Assessment
Pain
Itching
Swelling
Redness

& warmth

ERYSIPELAS & CELLULITIS:

Nursing Interventions
Promote

rest
Apply warm compress BID
Administer antibiotics after C/S
as ordered
Clean skin OD with antibacterial
soap

PSORIASIS
Chronic,

non-infectious skin inflammation

involving keratin synthesis psoriatic
patches
Most common: psoriasis vulgaris
Causes: stress, trauma, infection, changes
in climate, exacerbated by certain meds
Koebners phenomenon: development of
lesions at the site of injury (scratched or
sunburned area)

PSORIASIS: Assessment
Pruritus
Shedding,

silvery, white scales on a

raised reddened, round plaque on the
scalp, knees, elbows, arms & legs,
sacrum
Yellow discoloration, pitting, thickening
of nails
Joint inflammation with psoriatic arthritis

PSORIASIS: Assessment

PSORIASIS: Assessment

PSORIASIS: Assessment

PSORIASIS:
Nursing Interventions
Daily

soaks & tepid, wet compresses to

the affected areas to remove scales, oil
or coal tar prep. may be added to bath
water
Remove scales during soaks using soft
wash cloth in gentle, circular motions;
apply emollient creams or salicylic acid
after bath to soften thick scales

PSORIASIS:
Nursing Interventions
Topical

pharma tx
Tar prep, anthralin, salicylic acid,
corticosteroids, Vit. D, calcipotriene
(Dovonex), tazarotene (Tazorac): cause
sloughing of rapidly growing epidermal cells
Occlusive dressings post steroid application
to its effectiveness
Use plastic wraps (for feet), rubber gloves (for
hands), shower cap (for head), plastic vinyl
jogging suit if being treated at home

PSORIASIS:
Nursing Interventions
Intralesional

tx
Triamcinolone acetonide (Aristocort, Kenalog-10,
Trymex) injection to psoriatic patches that are
resistant to other forms of tx
Systemic tx
If resistant to other forms of tx
Methotrexate (Folex), hydroxyurea (Hydrea) &
cyclosporine A (CyA)
Photochemotx
Combo of photosensitizing meds (8methoxypsoralen) & long wave UV A light cellular
proliferation

PSORIASIS:
Nursing Interventions
Instruct

the pt
Not to scratch the affected areas &
keep the skin lubricated to itching
Recognize S/Sx of infection
Wear light cotton clothing
Meds compliance and avoid OTC
meds
Identify ways to stress

KAPOSIS SARCOMA
Skin lesions that occur primarily in
individuals with a compromised IS
Slow-growing tumor, raised,
oblong, purplish, reddish-brown
lesion, may be tender or not
Organs involved: lymph nodes,
airways or lungs, GI tract

KAPOSIS SARCOMA

KAPOSIS SARCOMA

KAPOSIS SARCOMA:
Nursing Interventions
Standard

precautions
Protective isolation
Prepare for radiation or chemotx
Administer immunotx as
ordered to stabilize the IS

HERPES ZOSTER (SHINGLES)

Acute

viral infection in the dorsal nerve root

ganglion caused by varicella zoster virus
Caused by reactivation or exposure to virus
or during immunocompromised state
Contagious to persons who have not had
chickenpox
Dx tests
Skin cultures & stains
Antinuclear Ab (ANA) blood test

HERPES ZOSTER (SHINGLES):

Assessment
Unilaterally clustered skin vesicles
along peripheral sensory nerves
on the trunk, thorax or face
Fever
Burning & neuralgia
Pruritus
Paresthesia

HERPES ZOSTER (SHINGLES):

Assessment

HERPES ZOSTER (SHINGLES):

Assessment

HERPES ZOSTER (SHINGLES):

Nursing Interventions
Isolate the pt, standard precautions,
contact precautions
Assess neurovascular status & CN
VII function
WOF infection
Keep blisters intact
Apply acetic acid compress, cool
wet compress & tepid baths

HERPES ZOSTER (SHINGLES):

Nursing Interventions
Assist

with nerve block using Lidocaine

Administer antiviral, analgesics, antianxiety,
antipruritics & corticosteroids as ordered
Use an air mattress & a bed cradle, keep
envt cool (warmth & touch aggravate pain)
Avoid scratching & rubbing the affected
area
Wear lightwt, loose cotton clothing, avoid
wool & synthetic clothing

PARONYCHIA
Infection

of the tissue around the nail plate

Common among middle-aged women & DM
pts
(+) redness, soreness & swelling around
nailbed
Monitor T, infection around nails, cellulitis
Assist with warm soaks
Assist with I & D as ordered
Administer antibiotic or fungicidal ointments
as ordered

IMPETIGO

infectious, caused by Group A hemolytic Streptococcus, possibly Staph

aureus
Predisposing factor: heavy infestation of
Pediculosis capitis then pick nose
Papulovesicular lesions (face, around mouth,
hands, neck, extremities) surrounded by
localized erythema becoming purulent and
ooze, forming a honey-colored crust
Cx: AGN
Highly

IMPETIGO: Nursing Interventions

Contact

isolation
(Communicable for 48hrs
without treatment)
Skin care
Allow lesions to dry
by air exposure
Daily bathing with antibacterial soap
(pHisoHex)
Warm compress 2-3X/day to remove crusts
Use of skin emollients to prevent cracking

IMPETIGO: Nursing Interventions

Proper

hygiene
Strict hand washing
Use separate towels, linens, dishes
(washed separately with detergent
in hot water)
Oral antibiotics
(Penicillin)
Antibiotic ointment
(Mupirocin)

BOILS
Deep

bacterial inflammation of hair follicles

caused by Staph. Aureus
Seen on the face, neck, arms, legs & groin
(+) redness & swelling on skin, tender & painful,
with yellow or white center at the furuncle
Observe strict hand washing
Apply hot moist compress
Assist with I & D
Instruct pt in daily cleanliness, use of separate
bath linens
Administer antibiotics as ordered

BOILS

FROSTBITE
Damage

to tissues & blood vessels as a

result of prolonged exposure to cold
Fingers, toes, nose & ears often are affected
S/Sx
Numbness, paresthesia
Pallor
Severe pain, swelling, erythema &
blistering once client is in a warm envt
Necrosis & gangrene in severe cases

FROSTBITE:
Nursing Interventions
Handle

the tissues gently

Rewarm the affected part rapidly and
conitnuously with warm water bath (90107F) for 15-20 mins. until skin flushing
Avoid slow thawing, interrupted periods of
warmth or massage
Do not debride blisters
Leave area exposed initially for assessment
& then apply bulky dressings to provide
protection

SCABIES

SCABIES

SCABIES
Infestation

of Sarcoptes scabiei (itch mite)

F mite burrows into epidermis, lay eggs &
dies after 4-5 wks
The eggs hatch in 3-5 days, larvae mature &
complete life cycle
Contagious during course of infestation via
direct contact with infected person or articles
Endemic among schoolchildren &
institutionalized pop.

SCABIES: Assessment
Erythematous

papules & pustules

Intense pruritus esp. at night
Threadlike, brownish linear
burrows 1 cm long
Secondary lesions: vesicles,
crusts, reddish-brown nodules &
excoriation

SCABIES:
Nursing
Interventions

Antihistamines or topical steroids as ordered

Topical scabicides
Lindane cream (Kwell, Scabene) should not be used for
<2 y/o: risk of neurotoxicity & seizures; Crotamiton
(Eurax)
Warm soap-and-water bath
Dry and cool skin (to CNS absorption)
Apply scabicide lotion thinly (from neck down since
face & scalp are not affected); leave for 12-24 hrs
before rinsing
Permethrin 5% (Elimite): cream is massaged thoroughly
and gently from head to soles; avoid contact with eyes

SCABIES: Nursing Interventions

Treat

all household members & close

contacts simultaneously
Strict hand washing
Change all clothing & bedding OD, wash
in detergent with hot water, hot dryer &
ironed or dry-cleaned before reuse (mites
can survive up to 36 hrs on linen)
Seal nonwashable toys & other items in
plastic bag for 4 days

ACNE
VULGARIS

Self-limiting, inflammatory skin disease

involving sebaceous glands
Unknown cause, may include androgenic influence on
sebaceous glands, sebum production & proliferation
of Propionibacterium acnes (enzymes which reduce
lipids to irritating FA)
Exacerbation coincide with
mens. cycle from hormonal
activity
Heat, humidity & excessive
perspiration have a role in
acne

ACNE VULGARIS: Assessment

ACNE VULGARIS: Assessment

ACNE VULGARIS: Assessment

Open

comedones
(blackheads)
Closed comedones
(whiteheads)
Pustules, papules
Nodules deep scarring

ACNE VULGARIS:
Nursing Interventions
Proper

hygiene, skin cleaning

methods not scrubbing the face,
not to squeeze, pick or prick the
lesions
Use products labeled noncomedogenic, water-based
cosmetics, not oil-based
Use mild sulfur (antibacterial)
soap

ACNE VULGARIS:
Nursing Interventions
Administer as ordered:
Antibiotics (oral or topical)
Anti-acne cream: Tretinoin (Retin-A),
Isotretinoin (Accutane) to sebum
production & sebaceous gland size
ADR: cheilitis (lip inflammation), skin
dryness, eye discomfort,
triglycerides
Avoid taking Vit A if taking
Isotretinoin
Improvement: after 4-6 wks of tx

DECUBITUS ULCER
Impairment

of skin integrity
Localized areas of necrosis of
the skin & SQ tissue caused by
pressure
Prevention of skin breakdown is
a major role of the nurse, esp.
for bedridden or immobile pts.

DECUBITUS ULCER

DECUBITUS ULCER:
Risk Factors
Malnutrition
Incontinence
Immobility
Skin-shearing

sensory perception

DECUBITUS ULCER:
Stages
1:

intact, reddened skin, returns to N skin

color after 15-20 mins. of pressure relief, do
not blanche
2: epidermis lost, shallow with pink or red
base, with white or yellow eschar
3: extends to dermis & SQ tissues, with
white, gray or yellow eschar at the bottom,
with purulent d/c
4: extends to muscle & bone, foul-smelling,
with brown or black eschar, with purulent d/c

DECUBITUS ULCER:
Stages

DECUBITUS ULCER:
Nursing Interventions
Assess nutritional status, provide
adequate nutritional intake to
promote tissue integrity
WOF altered skin integrity
Relieve or remove pressure on the
skin
Turn & reposition the pt q2h
Help the client to ambulate

DECUBITUS ULCER:
Nursing Interventions
Provide active & passive ROM q8h
Keep skin clean & dry & the sheets
wrinkle-free
Apply moisture barrier as ordered
Apply meds or dressings to the
wound as ordered
Use alternating air pressure
mattress or sheep-skin padding

BURN INJURIES
Cell

destruction of the layers of

the skin & the resultant
depletion of fluids & electrolytes

TYPE OF BURNS
Thermal:

flames, hot
liquids/objects, steam
Chemical: strong acids, alkalis,
organic compounds
Radiation: UV lights, x-rays or
radioactive source

TYPE OF BURNS
Electrical
Assess:

voltage, type of current,

contact site & duration of contact
Alternating current (more
dangerous than direct current)
asso. with CP arrest, ventricular fib,
tetanic muscle contraction, long
bone & cervical fracture

INHALATION INJURIES:
Smoke Inhalation
When

trapped in an enclosed, hot, smoked-filled

space
Assessment
Facial burns
Swelling of oro/nasopharynx
Singed nasal hairs
Flaring nostrils
Stridor, wheezing, dyspnea
Hoarse voice
Sooty (carbonaceous) sputum & cough

INHALATION INJURIES:
Smoke Inhalation

INHALATION INJURIES:
Direct thermal heat injury
Lower

airways: by inhalation of
steam/explosive gases or aspiration of
scalding liquids
Upper airways: (+)erythema, (+)edema,
mucosal blisters/ulceration obstruction
esp. during the 1st 24-48 hrs
Head & neck burns: monitored for airway
obstruction ET intubation

INHALATION INJURIES:
Smoke Poisoning
When

by-products of combustion were inhaled

bronchial ciliary action & in surfactant
Assessment
Mucosal edema of airways
Wheezing
After several hours, sloughing of
tracheobronchial epithelium hemorrhagic
bronchitis
ARDS

INHALATION INJURIES:
CO poisoning

CO: colorless,
odorless, tasteless,
with affinity for Hgb
200X greater than
O2, forming
carboxyHgb tissue
hypoxia

Blood
Level

Assessment

1-10%

Impaired visual acuity

11-20% Flushing, HA
21-30% N/, impaired dexterity
31-40% Vom,dizziness,syncope
41-50% HR, RR
>50%

Coma, death

BURN EXTENT: RULE OF NINES

Head

and neck: 9%
Trunk (A/P each): 18%
Arms (9% each): 18%
Legs (18% each): 36%
Perineum: 1%

BURN DEPTH

BURN DEPTH

BURN DEPTH
1st degree (Superficial thickness)
Mild to severe erythema (pink to
red), no blisters
Blanches with pressure
Painful, with tingling sensation
(eased with cooling) for 48 hrs
Heals in 3-7 days

BURN DEPTH

BURN DEPTH
2nd degree (Partial thickness)
Large blisters with edema
Extremely painful
Heals in 2-3 wks (deep partial
thickness: 3-6 wks)
Grafts may be used if healing
process is prolonged

BURN DEPTH

BURN DEPTH
3rd

degree (Full thickness)

Deep red, black, white, yellow or brown
area
Dry with edema
Little or no pain
Needs removal of eschar & split or full
thickness skin grafting
Scarring & contractions likely to develop
Heals in wks. to mos.

BURN DEPTH
4th degree (Deep full thickness)
Involves injury to muscle & bone
Black, (-) pain, (-) edema, (-)
blisters
Hard & inelastic eschar, needs
grafting
Heals in wks. to mos.

BURN LOCATION
Head,

neck & chest: pulmo Cx

Face: corneal abrasion
Ear: aurical chondritis
Hands & joints: intensive tx to
prevent disability

BURN LOCATION
Perineal area: autocontamination
by urine & feces
Circumferential burns: tourniquetlike effect compartment syndrome
Circumferential thorax burns:
inadequate chest wall expansion &
pulmo insufficiency

PATHOPHYSIOLOGY: BURN
Injured tissue
hyperK

Vasoactive substance
release
capillary
permeability
plasma seep to
tissues

Hct then hypoNa edema/anasarca (18-26 hrs

(3rd-4th day)
post burn, N: 2-3 wks post burn)
r/t RBC
damage &
blood
loss
volume
Pulmo. HTN r/t
arterial O2
CO, HR, BP

organ perfusion
Kidneys
GI
Oliguria
then
Ileus &
diuresis r/t dysfxn
fluid
reabsorpn
after days
to wks

Hypovolemic shock &

death

IS
Infxn
sepsis

MANAGEMENT:
EMERGENT PHASE
Begins: at the time of burn
Ends: with restoration of the cap.
permeability (fluid resuscitation),
usu. 48-72 hrs post burn
Goal: prevent hypovolemic shock
& preserve vital organ functioning

MANAGEMENT:
EMERGENT PHASE
Prehospital

Care
Begins: at the accident scene
Ends: when emergency care is obtained
Remove the pt from heat source
Assess ABC, asso. trauma
Conserve body heat, cover burns with
sterile or clean cloth
Remove constricting jewelry & clothing
Transport

MANAGEMENT:
EMERGENT PHASE
Prehospital

Care

MANAGEMENT:
EMERGENT PHASE
Prehospital

Care

MANAGEMENT:
EMERGENT PHASE
Emergency

Room Care (Major Burns)

Evaluate the degree & extent of burn
& treat life-threatening conditions
Ensure patent airway, Give 100% O2
%via non-rebreather face mask as
ordered if inhalation injury is
suspected until carboxyHgb levels
<15

MANAGEMENT:
EMERGENT PHASE
Emergency Room Care (Major
Burns)
Assess oropharynx for erythema
& blisters
WOF RR distress, prepare
intubation set at bedside
Monitor ABG & carboxyHgb
levels

MANAGEMENT:
EMERGENT PHASE
Emergency

Room Care (Major Burns)

Initiate peripheral IV access to
nonburned skin promixal to any
extremity burned or prepare for
central line insertion as ordered
WOF hypovolemia, give IVF as
ordered
Insert Foley cath, maintaining UO at
30-50 ml/hr

MANAGEMENT:
EMERGENT PHASE
Emergency

Room Care (Major Burns)

Maintain NPO status
Insert NGT as ordered to remove
gastric secretions & prevent aspiration
Administer tetanus prophylaxis, pain
meds as ordered
Prepare for escharotomy or
fasciotomy as ordered

MANAGEMENT:
EMERGENT PHASE
Emergency

Room Care (Minor Burns)

Instruct pt: follow-up care, active
ROM, wound care
Administer as ordered
Pain meds: Morphine or Demerol
Oral analgesics
Tetanus prophylaxis

MANAGEMENT:
EMERGENT PHASE
Emergency

Room Care (Minor Burns)

Wound care: cleansing, debriding
loose tissue, application or topical
antimicrobial cream & sterile
dressing
Administer as ordered Instruct pt:
follow-up care, active ROM, wound
care

MANAGEMENT:
RESUSCITATIVE PHASE
Begins:

with initiation of fluids

Ends: when cap. integrity
returns to near-N levels & large
fluid shifts
Goal: maintain adequate
circulating blood volume &
maintaining vital organ perfusion

MANAGEMENT:
RESUSCITATIVE PHASE
Fluid

Resuscitation (plain LR)

Parkland (Baxter) Formula
4ml X body wt (kg) X TBSA burned
Infuse in 1st 8 hrs post burn
in the 2nd & 3rd 8 hrs post burn
Modified Brooke Formula
2ml X body wt (kg) X TBSA burned
Infuse in 1st 8 hrs post burn
in next 16 hrs post burn

MANAGEMENT:
RESUSCITATIVE PHASE
Goal:

UO of 30-50 ml/hr (most

sensitive noninvasive assessment
parameter for CO & tissue perfusion)
Other parameters: stable VS,
palpable peripheral pulses, clear
sensorium
IVF rate: adjusted depending on UO,
serum electrolytes & Hgb & Hct levels

MANAGEMENT:
RESUSCITATIVE PHASE
Elevate

HOB to 30 for face & head

burns
Initiate ECG monitoring
Monitor T, WOF infection
Initiate protective isolation, strict HW,
aseptic technique, PPE
Shave/cut hair around wound margins
Weigh OD (expect wt gain of 15-20 lbs in
the 1st 72 hrs)

MANAGEMENT:
RESUSCITATIVE PHASE
WOF

stress ulcer, administer antacids, H2

receptor antagonists, Sucralfate (Carafate) as
ordered
Auscultate bowel sounds for ileus, WOF
abdominal distention
Monitor stools for occult blood
Obtain urine specimen for myoglobin & Hgb
levels
Elevate circumferential burns of the extremities
on pillows above heart level to edema

MANAGEMENT:
RESUSCITATIVE PHASE
Monitor pulses & cap. refill of distal
extremities
Keep the room T warm
Place the pt on an air-fluidized bed
and a use of bed cradle to keep
sheets off the pts skin
Prepare the client for x-ray to r/o
trauma, fractures

MANAGEMENT:
RESUSCITATIVE PHASE
Pain management
Administer morphine or Demerol
IV, esp. before painful procedures
Avoid IM or SQ routes since
absorption through soft tissue is
unreliable
Avoid giving meds po because of
GI dysfunction

MANAGEMENT:
RESUSCITATIVE PHASE
Nutrition
To

promote wound healing &

prevent infection since BMR is 40100 X higher than N
Maintain on NPO until bowel
sounds return
Can be given via NGT, PPN or TPN
High CHON, CHO, fats & vit.

MANAGEMENT:
RESUSCITATIVE PHASE
Escharotomy
Lengthwise

incision made through the burn

eschar to relieve constriction, pressure to
improve circulation (circumferential burns)
& to improve ventilation (thorax)
Done at bedside, no anesthesia
Assess CMS & bleeding (pack with sterile,
fine mesh gauze for 24 hrs)
Apply antibacterial ointment to the site as
ordered

MANAGEMENT:
RESUSCITATIVE PHASE
Fasciotomy
An

incision extending through the SQ &

fascia
Done if adequate tissue perfusion does not
return after escharotomy
Done in OR under GA
Assess CMS & bleeding (pack with sterile,
fine mesh gauze for 24 hrs)
Apply antibacterial ointment to the site as
ordered

FASCIOTOMY

MANAGEMENT:
ACUTE PHASE
Begins:

when the pt is
hemodynamically stable, cap.
permeability is restored & diuresis
occurs (usu. 48-72 hrs post burn)
Emphasis: restorative tx until wound
closure is achieved
Focus: infection control, wound care,
wound closure, nutritional support,
pain mgt, PT, rehab

MANAGEMENT:
ACUTE PHASE (Wound Care)
METHOD

OPEN
Antimicrobial
cream applied
q12h, wound
left open to the
air without a
dressing

ADVANTAGE

DISADVANTAGE

Visualization of
the wound
HypotherEasier mobility mia
& joint ROM
Simplicity in
wound care

MANAGEMENT:
ACUTE PHASE (Wound Care)
METHOD

ADVANTAGE

DISADVANTAGE

CLOSED
With gauze
dressings applied
q8-12 hrs
No 2 burn surfaces
should touch
(webbing of digits,
contractures, poor
cosmetic outcome)

evaporative fluid
& heat loss
Aids in
debridement

Mobility &
wound
assessment
limitation
prevents
effective
ROM

MANAGEMENT:
ACUTE PHASE (Wound Care)
Hydrotherapy
Cleansed

by immersion, showering,
spraying for <30 mins. to prevent
Na loss from wound, heat loss,
bleeding, pain & stress
Should be premedicated before
procedure
Not done for hemodynamically
unstable pt & with skin grafts

MANAGEMENT:
ACUTE PHASE (Wound Care)
Debridement
Removal

of eschar to prevent
bacterial proliferation to promote
wound healing
May be mechanical, enzymatic or
surgical
DPT or FT burns: wound is cleansed
& debrided, topical antimicrobial are
applied OD or BID

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Prevents

infection, fluid loss,

contractures; promotes healing
Performed on the 5th to 21st day
depending on burn extent

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Temporary

wound coverings
Biological
Amnion
From placenta, changed q48 hrs
Allograft homograft
Donated human cadaver skin (from skin
bank)
WOF infection (exudate)
Rejection can occur within 24 hrs

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Temporary

wound coverings
Biological
Xenograft homograft
Porcine skin after slaughter &
preserved
Rejection can occur within 24-72 hrs
Biosynthetic or Synthetic
Transparent or translucent dressings
WOF for infection

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Autografting
Provides permanent wound coverage
Surgical removal of thin layer of pts
unburned skin then applied to excised
burn wound
WOF bleeding (prevent skin
adherence)
Immobilized for 3-7d (to attach to
wound bed)

MANAGEMENT:
ACUTE PHASE (Wound Closure)

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Care

to the graft site

Elevate & immobilize graft site
Keep site free from pressure
Avoid wt bearing
WOF infection, hematoma or
fluid accumulation

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Care

to the graft site

Instruct the client to:
Avoid using fabric softeners &
harsh detergents in the laundry
Lubricate skin with cocoa butter
as ordered, protect skin from
sunlight
Use splints & support garments

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Care to the donor site
Moist dressing is applied at the time
of surgery to maintain pressure &
stop any oozing
Apply single-layer gauze impregnated
with petrolatum or with biosynthetic
dressing such as Biobrane
Keep the donor site clean, dry & free
from pressure

MANAGEMENT:
ACUTE PHASE (Wound Closure)
Care

to the donor site

Avoid scratching the site
Apply lubricating lotions to soften
the area & itching after the
donor site is healed
Site can be reused once healing
has occurred (usu. 7-14 days
with proper care)

MANAGEMENT:
ACUTE PHASE (PT)
Individualized program of splinting,
positioning, exercises, ambulation
& ADLs done early to maximize
functional & cosmetic outcomes
ROM exercises to edema &
maintain strength & joint function
Ambulate the pt to maintain LE
strength

MANAGEMENT:
ACUTE PHASE (PT)
Apply

splints to maintain proper joint

position & prevent contractures
Static splints are applied during periods
of immobilization, during sleeping & for
pt who cant maintain proper positioning
Dynamic splints exercise the affected
joint
Avoid pressure to skin areas with
splint tissue & nerve damage

MANAGEMENT:
ACUTE PHASE (PT)
Scarring is controlled by elastic
wraps & bandages that apply
continuous pressure to the healing
skin when vulnerable to shearing
Antiburn scar support garments
are worn 23 hrs/day until the burn
scar tissue has matured, which
takes 18 mos.- 2yrs

MANAGEMENT:
REHABILITATIVE PHASE
Final

phase of burn care

Overlaps with acute care phase,
goes beyond hospitalization

MANAGEMENT:
REHABILITATIVE PHASE
Goals
Pt

will gain independence &

maximal functions
Promote wound healing
Minimize deformities
strength & function
Provide emotional support

NCLEX/CG QUESTIONS

The nurse is reviewing the health care

record of the clients scheduled to seen at
the health care clinic. The nurse determines
that which of the following individuals is at
the greatest risk for development of an
integumentary disorder?
A. An older female
B. An adolescent
C. An outdoor construction worker
D. A physical education teacher

NCLEX/CG QUESTIONS

The nurse prepares to assist the physician

to examine the clients skin with a Woods
light. The nurse includes which of the
following in the plan for this procedure?
A. Obtain an informed consent.
B. Darken the room for the examination.
C. Shave the skin and scrub with povidone-iodine
solution.
D. Prepare a local anesthetic.

NCLEX/CG QUESTIONS
The clinic nurse provides instructions to a client
who is to return to the clinic in 1 week for a
scratch skin test. The test will be done to identify
the allergen causing the dermatitis. The nurse
provides which instruction to the client?

Do not ingest anything before the test.

Shower using an antibacterial soap on the morning of the
test.
Discontinue the prescribed antihistamine 5 days before
the test
Consume only fluids on the day of the test.

NCLEX/CG QUESTIONS

The nurse provides discharge instructions to

a client following patch testing. Which
statement if made by the client would
indicate the need for further instruction?

I will return to the clinic in 2 days for the initial

reading.
If the patch comes off, I need to reapply it.
I need to avoid activities that will cause me to
sweat.
I need to keep the test sites dry at all the times.

NCLEX/CG QUESTIONS
The camp nurse prepares to instruct a group of
children about Lyme disease. Which of the
following information would the nurse include in
the instructions?

Lyme disease can be contagious by skin contact with an

infected individual.
Lyme disease can be caused by inhalation of spores from
bird droppings.
Lyme disease is caused by contamination from cat feces.
Lyme disease is caused by a tick carried by deer.

NCLEX/CG QUESTIONS

The client is diagnosed with stage 1 of Lyme

disease. The nurse assesses the client for
which characteristics of this stage?

Signs of neurological disorders

Enlargement and inflamed joints
Arthralgias
Flu-like symptoms

NCLEX/CG QUESTIONS
A female client arrives at the health care clinic and
tells the nurse that she was just bitten by a tick and
would like to be tested for Lyme disease. The
client tells the nurse that she removed the tick and
flush it down the toilet. Which of the following
nursing actions is most appropriate?

Refer the client for blood test immediately.

Informed the client that there is not a test available for
Lyme disease.
Instruct the client to return in 4 to 6 weeks to be tested
because testing before this time is not reliable.
Tell the client that testing is not necessary unless
arthralgia develops.

NCLEX/CG QUESTIONS

Following diagnosis of stage 1 of Lyme

disease, the nurse would anticipate that
which of the following will be part of the
treatment plan for the client?

No treatment unless symptoms develop.

A 3-week course of oral antibiotic therapy.
Treatment with intravenously administered
antibiotics.
Daily oatmeal baths for a period of 2 weeks.

NCLEX/CG QUESTIONS
A Cub Scout leader who is a nurse is preparing a
group of Cub Scouts for an overnight camping trip
instructs the scouts about the methods to prevent
Lyme disease. Which statement by one of the Cub
scouts indicates a need for further instructions?

I should not use insect repellents because it will attract

ticks.
I should wear long-sleeved tops and long pants.
I need to bring a hat to wear during the trip.
I need to wear closed shoes and socks that can be pulled
up over my pants.

NCLEX/CG QUESTIONS

The client with acquired immunodeficiency

syndrome is diagnosed with cutaneous
Kaposis sarcoma. Based on the diagnosis,
the nurse understands that this has been
confirmed by which of the following?

Appearance of reddish blue lesions noted on the

skin.
Swelling in the lower extremities
Punch biopsy of the cutaneous lesions
Swelling in the genital area.

NCLEX/CG QUESTIONS

Which of the following individuals is least

likely at risk for the development of Kaposis
sarcoma?

A male with a history of same-sex partners.

A kidney transplant client
A client receiving antineoplastic medications.
An individual working in an environment where
exposure to asbestos exists.

NCLEX/CG QUESTIONS

The nurse prepares to care for a client with

acute cellulitis of the lower leg. The nurse
anticipates that which of the following will be
prescribed for the client?

Warm compresses to the affected area

Cold compresses to the affected area
Intermittent heat lamp treatments 4 times daily.
Alternating hot to cold compresses continuously

NCLEX/CG QUESTIONS

The clinic nurse assesses the skin of a

white client with a diagnosis of psoriasis.
The nurse understands that which
characteristic is associated with this skin
disorder?

Clear, thin nail beds

Silvery white scaly patches on the scalp, elbows,
knees, and sacral regions
Oily skin and no-episodes of pruritus
Red-purplish scaly lesions.

NCLEX/CG QUESTIONS

The clinic nurse notes that the physician

has documented a diagnosis of herpes
zoster (shingles) in the clients chart. Based
on an understanding of the cause of this
disorder, the nurse would determine that
this definitive diagnosis was made following
which diagnosis test?

Skin biopsy.
Woods light examination.
Culture of the lesion.
Patch test

NCLEX/CG QUESTIONS

The nurse is assigned to care for a client

with herpes zoster (shingles). Which of the
following characteristics would the nurse
expect to note when assessing the lesions
of this infection?

A generalized body rash

Small, blue-white spots with a red base
A fiery red, edematous rash on the cheeks
Clustering skin vesicles.

NCLEX/CG QUESTIONS

The nurse manager is planning the clinical

assignments for the day. The nurse
manager avoids assigning which of the
following staff members to the client with
herpes zoster?

The nurse who never had mumps

An experienced registered nurse who never had
chickenpox.
The nurse who never had roseola
The nurse who never had German measles.

NCLEX/CG QUESTIONS

The health education nurse provides instructions to a

group of clients regarding measures that will assist in
preventing skin cancer. Which statement if made by
a client indicates a need for further education?
I will use sunscreen when participating in out-door
activities.
I will examine my body monthly for any lesion that
may be suspicious.
I will wear hat, opaque clothing, and sunglasses
when in the sun.
I will avoid the sun exposure after 3pm.

NCLEX/CG QUESTIONS

The nurse is preparing to care for a burn

client scheduled for an escharotomy
procedure being performed on a thirddegree circumferential arm burn. The nurse
understands that the anticipated therapeutic
outcome of the escharotomy is

Brisk bleeding from the site

Formation of granulation tissue
Decreasing edema formation
Return of the distal pulses

NCLEX/CG QUESTIONS

The nurse is caring for a client who

sustained 2nd- and 3rd-degree burns on the
anterior lower legs and anterior thorax.
Which of the following does the nurse
expect to note during the emergent phase of
the burn injury?

Decreased HR
Increased BP
Elevated Hct levels
Increased urinary output

NCLEX/CG QUESTIONS

The nurse is caring for a client who suffered

an inhalation injury from a wood stove. The
carbon monoxide blood report reveals a
level of 12%. Based on this level, the nurse
would anticipate which of the following signs
in the client?

Flushing
Dizziness
Tachycardia

Coma

NCLEX/CG QUESTIONS

The client arrives at the ER following a burn

injury that occurred in the basement at
home. An inhalation injury is suspected.
Which of the following would the nurse
anticipate to prescribed for the client?

100% oxygen via an aerosol mask

oxygen via nasal cannula at 15 LPM
100% ocygen via tight fitting, non-rebreather face
mask
oxygen via nasal cannula at 10 LPM

NCLEX/CG QUESTIONS
The nurse is administering IV fluids as prescribed
to a client who sustained 2nd- and 3rd degree burn
injuries of the back and legs. In evaluating the
adequacy of fluid resuscitation, the nurse
understands that which of the following would
provide the most reliable indicator for determining
the adequacy?

Vital signs
Urine output
Peripheral pulses
Mental status

NCLEX/CG QUESTIONS

The nurse is caring for a client following an

autograft and grafting to a burn wound on
the right knee. Which of the following would
the nurse anticipate to be prescribed for the
client?

Immobilization of the affected leg

Out of bed
Placing the affected leg in a dependent position
Bathroom privileges

NCLEX/CG QUESTIONS
The adult was burned as a result of an explosion. The
burn initially affected the clients entire face
(anterior half of the leg), and the upper half of the
anterior torso and there were circumferential burns
to the lower half of both of the arms. The clients
clothes caught on fire, and the client ran, causing
subsequent burn injuries to the posterior surface of
the head and the other half of the posterior torso.
Using the Rule of Nines, what would be the extent
of the burn injury? ______________________