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Med-Surg Ch 15-16-17

Skin and Burns

3 Skin Layers Subcutaneous fat: Innermost layer covers bone, Insulation, Source of energy Dermis: Second layer, Connective tissue, Collagen, Elasticity, Flexibility, Strength, Blood supply Epidermis: Outermost layer, Contains melanin and keratin
Additional Skin Anatomy Hair: You can live without it, Warmth, Now cosmetic Nails: Scratching, Grasping, You can live without them Glands: Sebaceous and Sweat glands
What to included in a skin assessment Shelter/soap/water/afford prev? Drugs (scab eating, photosensitivity) Allergies (detergent) Nutrition (protein/water) Family Hx (cancer, fair) Current Dx (stretch marks, atrophy, pressure ulcers) Onset/Characteristics/Severity/Relieving factors
Genetic Factors of Skin Ask about disorders in immediate family and gender of family member Examples: Albinism, Keloids, Vitiligo (White patches on skin), Baldness Hirsutism (Excessive hair), Skin Cancer
More Skin Assessment Color Lesions (primary and secondary) Pruritus/lichenified Edema Assess each lesion for: o A—asymmetry of shape o B—border irregularity o C—color variation within one lesion o D—diameter >6 mm
Skin Lesions Primary o Macule, patch o Papule, plaque o Nodule, tumor o Vesicle, bulla o Wheal o Pustule o Cyst Secondary o Atrophy o Erosion o Lichenification o Scales o Cust o Ulcer o Fissure o Scar o Keloid
Identifying Skin Integrity Skin tears o Thin skin, less elasticity o Pulling up in bed o Tape for IVs o Pets Cleanliness o Psychological o social-economical Tattoos and piercings o Considered skin lesion
Skin Changes Associated with the Elderly > atrophy < wound healing, inflammatory response > sensitivity to sun Dry skin (Xerosis), Wrinkles, Cherry angiomas < sensory perception > risk for hypothermia, heat stroke (< sweat prod) Hyperpigmentation (liver/age spots) > risk for shearing, ski
Palpation touch it! Confirms size of the lesions Determines flat or raised o Macular—flat rash o Papular—raised rash Skin temperature o Use back of hand Turgor o Pinch clavicle or sternum
Skin Diagnostics Cultures o Fungal infections (scrape w/ tongue blade) o Bacterial inf. (throat swab) o Viral inf. Skin biopsies: (#1 for skin cancer) o Punch biopsy (small chunk of skin) o Shave biopsy (horizontal) o Incisional biopsy o Excisional biopsy (remove
Hair Basics Distributed all over body except: palms, soles, nipples, inside genital area, lips Root enclosed in follicle Shaft exposed and consists mainly of dead cells In nare, trap bacteria and foreign debris Insulation Protects eyes Reduces laceration risks
Hair Assessment Cleanliness o Dandruff Distribution o Hirsutism o Bald spots Quantity and quality
Nail Assessment Dystrophic nails (abnormal nail) Color of nail plate o < color = < oxygen/blood flow Nail shape changes Nail thickness, consistency, lesions o Thicken with age, trauma, infection Acute and chronic paronychia o Inflammation of the area around the na
Pruritis Primary Cause = Emotional stress Secondary Cause = Disease, liver problems, Meds, Diabetes Subjective “Itch-scratch-itch” cycle Comfort: Lotion, Fluids, Distraction, Cool temps < itch sensation, oatmeal, baking soda, oils, Trim nails, antihistamines
Xerosis (Dryness) Common among older patients Fine flaking and pruritus = scratching = may result in open wounds Relieve itching Avoid hot baths
Urticaria (Hives) White or red edematous papules or plaques Remove triggering substances Client has been exposed to something, Antihistamines release, leaving wheals behind May use steroids to treat
Psoriasis Chronic immune disorder Raised reddened round plaques Silvery white scales Pruruitis (severe itching) Usually seen around age 30 Caucasian men and women Psoriasis vulgaris (thick reddened plaques) Psoriasis arthritis (affects joints)
Psoriasis Triggers Stress Irritation Cold/dry weather Steroid withdraw
Psoriasis Treatments Corticosteriods Tar preps (Suppress cell division) UV light (even tanning beds) Photochemotherapy Propanolol Medicated shampoo Immunosuppressant meds
Bacterial Skin Infections Folliculitis (shaved bump, staff infection, red, pustulous) Furuncle (boil, much deeper, firm) Carbuncle (group of infected hairs) Cellulitis (deep tissue, large area, red, edematous, warm, chills, malaise) Culture, treat with antibiotic
MRSA Resistant to broad-spectum antibiotics Resists penicillin, amoxicillin Small raised, red nodule resembles pimple or spider bite Rapidly increases in size, color, pain Abscess Potentially fatal
Hospital Acquired MRSA Wound IV Foley catheter
Community Acquired MRSA Unsanitary living conditions Football – community sweat rag
Treat MRSA Wound or Blood culture Antibiotics: Bactrim, Vibramycin, Mupirocinointment (Bactroban) Antiseptic body washes
MRSA Prevention Wash hands Don’t save antibiotic for later, TAKE THEM ALL! Don’t share personal items (razor, towel, athletic equipment) Shower after games with soap and water Don’t pop zits
Fungal Infections (Dermatophyte) Tineapedis (Athletes foot) Tineamanus (Hands) Tineacruris (Jock itch, thighs, buttocks) Tineacapitis (Head) Tineacorporis (body, ringworm, happens in large circular patterns like a ring) Candida albicans (Yeast, Mouth, skin folds, under breasts, geni
Fungal Infections (Dermatophyte) Diagnostics KOH Cultures Wood’s Lamp (ultraviolet inspection)
Fungal Infections (Dermatophyte) Treatments Clotrimazole(Mycelex) topical Miconazole(Monistat) topical Nystatin(Mycostatin) topical or oral rinse Fluconazole(Diflucan) pill
Pediculosis Lice Pediculosiscapitis (Head) Pediculosiscorporis (Body) Pediculosispubis (Genitals)
Pediculosis Manifestations Itching Knits in hair Transmitted by physical contact (Combs, towels, hair bows, hats, clothes)
Pediculosis Treatments Drugs= sprays, creams, shampoos, combs to pick knits Laundering of clothing and bed linen in HOT water
Scabies Contagious mite (burrows under skin and lays eggs) Found in webs of fingers, wrist, elbow, axillae, nipple, penis, and belt line Dx: lesion scrapings under microscope Rx: similar to lice, launder in hot water, K-oil, Scabasin, Treat itch with topical
HPV-Warts Non genital or genital Common areas: fingers, forehead, genitals, feet Rx: Acid therapy, Cryosurgery, Liquid nitrogen, Electrical, Immune system
Herpes Simplex Virus Fever blister or cold sore Type 1 (HSV-1) a. Usually mouth b. Can appear on genitalia Type 2 (HSV-2) a. Usually genitalia b. Can appear on mouth
Herpes Simplex Virus Manifestations and Treatments Tingly Erupts, blister Heal in 10-14 days Triggers (Sunlight, Menstruation, Injury, Stress) Spread by direct contact Meds (Acyclovir, Abreva)
Herpese Zoster/Shingles Reactivation of dormant varicella Lesions over dermatone with nerve involvement Shows on nerve line Manifestations: itching and pain generally unilateral, multiple vesicles Neuralgia (nerve pain)
Herpese Zoster/Shingles Assessment and Labs Diagnosed with clinical manifestations History Tzancksmear Swab culture
Herpese Zoster/Shingles Medications Acycliver Lytoderm patches (relieve pain, put on shingle site, expensive, antihistamine for itching also) Zostavax (Vaccine, weakened form of varicella)
Common Inflammations Contact dermatitis Atopic dermatitis (Eczema, Seasonal allergies) SeborrheicDermatitis (Inflammation of skin around hair, brow, lashes, areas that secrete oil) ExfoliativeDermatitis (Excessive shedding of the skin)
Interventions for Common Inflammations Steroids Avoidance of oil-based products Antihistamines Compresses and baths Removing allergen
2 Kinds of Acne Noninflammatory comedones (white/black head) Inflammatory papules, pustules, and cysts (pimple)
3 Kinds of Inflammatory Acne Acne Vulgaris (teen-adult, face/neck/back/chest/shoulders, may scar, < self-esteem) Acne Rosacea (erythema on checks/nose, middle to older adult) Acne Conglobata (middle adulthood, white/black head, pimple/cyst, scars, buttocks/chest, purulent/malodorou
Acne Treatments Topical agents (face wash, remove makeup, wash 2x daily, don’t touch face, eat balanced diet, get sun exposure, exercise, don’t pop zits, follow treatment plan) Systemic antibiotics Isotretinoin(Accutane) (Not while pregnant, blood work every month)
Other Skin Disorders Lichen Planus (itch/flat/purple papules, wrist/forearm, steroid/antihistamine) Pemphigus Vulgaris (chronic blistes, rare, autoimmune, steroid/chemo) Toxic Epidermal Necrolysis (drug reaction, peal) Stevens-Johnson Syndrome (Penicillin/Sulfa-drug caused
Benign Tumors Cysts Seborrheic keratoses (thickening over growth of skin), dark patches, doesn’t hurt, removed for cosmetic) Keloids Nevi (moles) Angiomas Skin tags (excessive irritation under bra, breast, collar, eyes)
Skin Cancers Actinic keratoses (Premalignant lesions, can turn to skin cancer, bleeds easily, shiny) Non-melanoma (squamous cell carcinomas, basal cell carcinomas) Melanomas (highly metastatic; survival depends on early diagnosis and treatment)
Risk Factors for Non-melanoma Skin Cancer Fair skin, flecked, blue/green eyes Blonde or red headed Family hx Unprotected and/or excessive UV exposure Severe Sunburns as a child Occupational HPV Organ transplant with immunosuppressive drugs
Non-melanoma Skin Cancer Basal Cell Basics Most common, least aggressive Tends to recur Rarely Metasizes
5 Types of Non-melanoma Skin Cancer Basal Cell Nodular (face/neck/hands, itchy/white/angiomas) Superficial (trunk/extremities/flat/ulcerate/heal) Pigmented (blue/black/brown; head/neck/face; shinny) Morpheaform (rare; head/neck; ivory/fleshy; scar-like) Keratotic (metastisis; pre/postaricular; nod
Non-melanoma Skin Cancer (Squamous Cell) Areas of exposure to UV and weather More aggressive Greater risk for metastasis Small, firm red nodule Increase size=ulcerate, bleed, painful Develops into a nodule that is indurated (hard nodule)
Skin Cancer Surgery Biopsy Surgical excision Curettage and electrodesiccation (0pen up, electrocute cancer) Mohs’ surgery (thin shaving) Radiation (better cure rate, less tissue removed) Others
Melanoma Risk Factors # of moles Fair skin, freckled blonde/red haired, blue eyes Family hx UV radiation from sunlight Over age of 50 Xeroderma pigmentosus (genetic disorder, can look like bad acne) Hx of melanoma
What dose Melanoma Look Like >6 mm in diameter (an eraser) Asymmetric (irregular shape)
4 Types of Melanoma Superficial spreading (flat/scaling from mole, back/neck/legs, red/white/blue) Lentigomaligna (brown shades, sun exposure, modeled, cold/bluish) Nodular (raised dome, blue/black, like blood blister) Acral (palms/soles/mucous, > dark skin, brown/black)
Melanoma Diagnosed by Biopsy
Melanoma Treatments Wide excision (take mole, surrounding area, and may even take lymph nodes) Immunotherapy Radiation Biological Therapy
Health Promotion to Prevent Melanoma Sun screen Decrease sun exposure Slip on a shirt Slop on sunscreen Slap on a hat
Hints to Malignant Melanoma ABCDE + ugly duckling sign i. Asymmetry ii. Borders iii. Color iv. Diameter v. Evolving
Pressure Ulcer Definition Skin breakdown Impearled blood flow Boney prominences
Mechanical Forces Pressure Friction (rubbing, pulling up in bed) Shear (falling down in bed)
High Risk Clients for Pressure Ulcers Elderly Bed rest Extensive surgeries Handicap/wheelchair (position ever 15 min) Poor nutrition Decreased sensation Incontinence (feces and urine accelerate skin breakdown)
Pressure Relieving Techniques Key to prevention Products and devices Positioning/Transferring Skin care (do not massage boney prominences that are red)
Staging a Pressure Ulcer Stage I (red non-blanchable, skin intact) Stage II (skin not intact, blister, shallow crater, partial thickness skin loss) Stage III (full thickness skin loss, damage to fascia, tissue, or muscle) Stage IV (bone, muscle, tendon exposed)
Wound Assesment Staging Location Size (LxWxD) Color (Granulation tissue, slough, use percentages) Extent of tissue involvement Wound base and margins (rolled, cupped, edges, maceration) Exudate (COCA) Condition of surrounding tissue Presence of foreign bodies (ma
Wound Dressings Mechanical debridement (detachment of dead tissue, scrub, wet to moist (or dry) dressing) Natural chemical debridement (Santyl ointment) Hydrophobic material (Wet to dry, little to no drainage) Hydrophilic material (wet to moist, lots of drainage)
Nonsurgical Wound Therapies PT (walk/position/trapeze/debris/whirlpool) Rx (antibiotic, Dakins, GPC, Santyl, Silvadine) Nutrition therapy Others: Electrical stimulation; Anadime Machine; Vacuum-assisted; Hyperbaric O2 (> O2 under high pressure, Tx life/limb/spider bites/osteomeli
Surgical MGT of a Wound Surgical debridement Skin grafting (Can’t remove without physician’s order)
Plastic surgery (necessary or cosmetic) Skin Grafts/flaps Chemical peeling (Can predict, firmer, less wrinkled skin) Liposuction Dermabrasion (light chemical freezing then scraping with a sandpaper-like product) Facial cosmetic i. Rhinoplasty-nose ii. Blepharoplasty-eye iii. Rhytidectomy
Burn Definition An injury caused by a heat source that causes physiologic changes and damage to the tissue Skin can grow as long as dermis is present
Burn Pathophysiology Skin changes resulting from burn injury (anatomic changes) If entire dermis is burned, skin can no longer restore itself (functional changes) Unable to maintain electrolyte balance and act as a barrier (temp) Cells are destroyed by increasing temperatu
Factors Associated with Burns Age (sunburn exposure, < sensation, dementia, elderly and children are more prone) Smoking carelessly Alcohol and drug intoxication Physical or mental disabilities Certain occupations Look for abuse (Cigarette burns)
4 Kinds of Burns Thermal Chemical injury Electrical injury Radiation injury
Burn Priority Neutralize Flush CPR Corticosteroids Increase fluids Cool water
Depth of Burn Injury Superficial-Thickness (pink-red, blanchable/chills/headache, N/V, skin peals) Partial thickness (red/blister, pale/waxy, large blisters) Full Thickness (no cells to repopulate, pale/waxy/yellow/brown/mottled/charred/non-blachable/hard/dry/leathery/edema
Measure % of Body with Rule of 9's: Anterior and Posterior Head/Neck = 9 Upper Limbs = 18 Trunk = 36 Perineum = 1 Lower Limbs = 36
Complications of Major Burns Integumentary Cardiovascular Respiratory GI Urinary Immune Metabolism
Emergent Phase of Burns First 48 hr: Fluid loss,Maintain body temperature Goals of management include: o Secure airway o Support circulation—fluid replacement o Prevent infection o Maintain body temperature o Provide emotional support
Injuries to Respiratory from Burns Direct airway injury (Fire burn) Carbon monoxide poisoning (more binding than O2, Takes over cells, Visual impairment, coma, death, odorless, colorless) Thermal injury (Smoke poisoning, Toxic gas) Cyanide poisoning (Headache, seizure)
Cardiovascular Issues from Burns Hypovolemic shock Monitor vital signs, cardiac status, heart monitor Restore fluid
Renal/Urinary Trauma from Burns Changes are related to cellular debris and decreased renal blood flow Myoglobin is released from damaged muscle and circulates to the kidney Assess (BUN, Creatinine, Serum sodium levels) Examine urine color, odor, and presence of particles or foam
Gastrointestinal Issues from Burns Changes in GI function are expected Assess for GI bleeding, Paralytic ileus
Emergent/Resuscitative Phase of Burn Onset of injury to Fluid restoration Estimate extent of injury First Aid Respiratory Management Fluids Monitor urine output Hemodynamic monitoring
Acute Phase of Burn Injury Diuresis to wound closure Wound management Nutritional therapies (Enteral or TPN) Control infection Pain management
Escharotomy Longitudinal incision to release taut skin and allow for expansion from edema
Surgical Debridement for Burn Fasciectomy (Full-thickness burns only, fat and lymphatic tissue loss) Mechanical Enzymatic
Auto-grafting I give to me
Biologic and biosynthetic dressings Homograft (Another human) Heterograft (Pig skin) DuoDerm dressing
Dressing the Burn Wound Open or closed Positioning, Splints and Exercise (Prevent contractures, Ambulate ASAP) Support Garments (reduce scaring, Jobst garment 6 mo – 1 yr)
Topical Antibiotics Sulfamylon (it burns) Silver Nitrate (blackens everything it comes in contact with, use only in first 72 hrs) Silvadene (silver sulfadiazine)(marked leukopenia, but corrects itself)
Other Meds Systemic antibiotics Tetanus H2 blockers or PPI
Rehabilitative Stage Wound closure till return of highest level of health Biopsychosocial Prevention of contractures Vocational, occupational, physical rehabilitation
Created by: nimeggs