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Med-Surge 2 Exam 2 > Skin Disorders > Flashcards

Skin Disorders Flashcards

1
Q

skin

A

plays a major role in protection by acting like the first line of defense, as well as helps regulate body temperature and maintains fluid and electrolyte balance

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2
Q

hair

A

differs in type and function in various body areas

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3
Q

nails

A

are useful for grasping and scraping and have cosmetic value

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4
Q

changes in epidermis related to aging

A

Physical changes: decreased epidermal thickness  skin transparency and fragility
Nursing interventions: handle patients carefully to reduce skin friction and shear; assess for excessive dryness or moisture; avoid taping the skin
Physical changes: decreased cell division  delayed wound healing
Nursing interventions: avoid skin trauma, and protect open areas
Physical changes: decreased epidermal mitotic homeostasis  skin hyperplasia and skin cancers (especially in sun-exposed areas)
Nursing interventions: assess non–sun-exposed areas for baseline skin features; assess exposed skin areas for sun-induced changes

Physical changes: increased epidermal permeability  increased risk for irritation
Nursing interventions: teach patients how to avoid exposure to skin irritants
Physical changes: decreased immune system cells  decreased skin inflammatory response
Nursing interventions: do not rely on degree of redness and swelling to correlate with the severity of skin injury or localized infection
Physical changes: decreased melanocyte activity  increased risk for sunburn
Nursing interventions: teach patients to wear hats, sunscreen, and protective clothing; teach patients to avoid sun exposure from 10amto 4pm

Physical changes: hyperplasia of melanocyte activity (especially in sun-exposed areas)  changes in pigmentation (e.g., liver spots, age spots)
Nursing interventions: teach patients to keep track of pigmented lesions; teach them what changes should be evaluated for malignancy
Physical changes: decreased vitamin D production  increased risk for osteomalacia
Nursing interventions: urge patients to take a multiple vitamin or a calcium supplement with vitamin D
Physical changes: flattening of the dermal-epidermal junction  increased risk for shearing forces, resulting in blisters, purpura, skin tears, and pressure-related problems
Nursing interventions: avoid pulling or dragging patients; assist patients confined to bed or chairs to change positions at least every 2 hours; avoid or use care when removing adhesive wound dressings

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5
Q

changes in the dermis related to aging

A

Physical changes: decreased dermal blood flow  increased susceptibility to dry skin
Nursing interventions: teach patients to apply moisturizers when the skin is still moist and to avoid agents that promote skin dryness
Physical changes: decreased vasomotor responsiveness  increased risk for heat stroke and hypothermia
Nursing interventions: teach patients to dress for the environmental temperatures
Physical changes: decreased dermal thickness  paper-thin, transparent skin with an increased susceptibility to trauma
Nursing interventions: handle patients gently, and avoid the use of tape or tight dressings; use lift sheets when positioning patients

Physical changes: degeneration of elastic fibers  decreased tone and elasticity
Nursing interventions: check skin turgor on the forehead or chest
Physical changes: benign proliferation of capillaries  cherry hemangiomas
Nursing interventions: teach patients that these are benign
Physical changes: reduced number and function of nerve endings  reduced sensory perception
Nursing interventions: tell patients to use bath thermometer and to lower the water heater temperature to prevent scalds

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6
Q

changes in the subcutaneous layer related to aging

A

Physical changes: thinning subcutaneous layer  increased risk for hypothermia and increased risk for pressure injury
Nursing interventions: teach patients to dress warmly in cold weather; assist patients confined to bed or chairs to change positions at least every 2 hours

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7
Q

skin inspection

A

observe and document these features:
Obvious changes in color and vascularity
Presence or absence of moisture
Edema
Skin lesions
Skin integrity

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8
Q

Skin assessment techniques for patients with darker skin

A

Pallorcan be detected in people with dark skin by first inspecting the mucous membranes for an ash-gray color
Cyanosis can be detected in the lips and tongue appearing gray and the palms, soles, conjunctivae, and nail beds have a bluish tinge
Inflammationin dark-skinned patients appears as excessive warmth and changes in skin consistency or texture
Jaundiceis best assessed by inspecting the oral mucosa, especially the hard palate, for yellow discoloration
Ecchymoses appear darker than normal skin; they may be tender and easily palpable

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9
Q

Primary lesions

A

are an initial reaction to a problem that alters skin components

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10
Q

Secondary lesions

A

changes in the appearance of the primary lesion; these changes occur with progression of an underlying disease or in response to a topical or systemic therapeutic intervention

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11
Q

Annular

A

circular

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12
Q

Circumscribed

A

well-defined with sharp borders

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13
Q

Clustered

A

several lesions grouped together

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14
Q

Coalesced

A

lesions that merge with one another and appear confluent

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15
Q

Linear

A

occurring in a straight line

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16
Q

Serpiginous

A

with wavy borders, resembling a snake

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17
Q

Universal

A

all areas of the body involved, with no areas of normal-appearing skin

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18
Q

Skin palpation

A

use palpation to gather additional information about skin lesions, moisture, temperature, texture, and turgor
Palpation confirms lesion size and whether they are flat or slightly raised
Consistency of larger lesions can vary from soft and pliable to firm and solid
Subtle changes, such as the difference between a finemacular rash and apapular rash, are best determined by palpating with your eyes closed
Ask the patient whether skin palpation causes pain or tenderness

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19
Q

diagnostic labs/tests

A

cultures
Skin biopsy
Wood’s light examination
Diascopy

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20
Q

pressure ulcer

A

is a loss oftissue integritycaused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period
Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death
Complications include sepsis, kidney failure, infectious arthritis, and osteomyelitis

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21
Q

assess for any contributing factors for pressure ulcers

A

Prolonged bedrest
Immobility
Incontinence
Diabetes mellitus
Inadequate nutrition or hydration
Decreased sensory perception or cognitive problems
Peripheral vascular disease
Friction and sheering forces
Inspect the whole body

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22
Q

Incontinence associated dermatitis (IAD)

A

Skin damage associated with exposure to urine or stool
It is a type of irritant contact dermatitis
Once IAD occurs, there is a high risk for pressure ulcer development as well as an increased risk of infection and morbidity

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23
Q

Stage I pressure ulcer

A

Skin is intact, red and does not blanch with external pressure
For patients with darker skin that does not blanch:
Observe for changes compared with an adjacent or opposite area for:
Skin color darker or lighter than the comparison area
Skin temperature (warmth or coolness)
Tissue consistency (firm or boggy)
Sensation (pain, itching)

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24
Q

Stage II pressure ulcer

A

There is partial-thickness skin loss of the epidermis or dermis and skin is not intact
Ulcer is superficial and may be characterized as an abrasion, a blister (open or fluid-filled), or a shallow crater
Bruising isnotpresent

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25
Q

stage III pressure ulcer

A

Skin loss is full thickness and damage extends down to but not through the underlying fascia; bone, tendon, and muscle arenot exposed
Subcutaneous tissues may be damaged or necrotic
Undermining and tunneling may or may not be present

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26
Q

Stage IV pressure ulcer

A

Skin loss is full thickness with exposed or palpable muscle, tendon, or bone
Often includes undermining and tunneling
Slough and eschar are often present on at least part of the wound

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27
Q

Deep tissue injury

A

The intact skin area appears purple or maroon
Blood-filled blisters may be present
The area may have felt more firm, boggy, mushy, warmer, or cooler than the surrounding tissue before the color change occurred

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28
Q

Unstageable pressure ulcer

A

Skin loss is full thickness, and the base is completely covered with slough or eschar, obscuring the true depth of the wound

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29
Q

assessment and document for pressure ulcers

A

Assess wounds for location, size, color, extent of tissue involvement, cell types in the wound base and margins, exudate, condition of surrounding tissue, tunneling, undermining and presence of foreign bodies
Document this initial assessment to serve as a starting point for determining the intervention plan and its effectiveness
Assess the wound at each dressing change, comparing the existing wound features with those documented previously to determine the current state of healing or deterioration

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30
Q

assess for signs of healing

A

Beneath the dead tissue, granulation tissue appears
Early granulation is pale pink, progressing to a beefy red color as it grows and fills the wound
Palpate the wound to determine the granulation texture
Healthy granulation tissue is moist and has a slightly spongy texture

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31
Q

Nursing interventions for pressure-relieving and pressure reducing techniques

A

Assist with major position changes every 2 hours in bed, every 1 hour in a chair
Pad contact surfaces with foam, silicon gel, air pads, or other pressure-relieving pads
Do not keep the head of the bed elevated above 30 degrees to prevent shearing
Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her
When positioning a patient on his or her side, do not position directly on the trochanter
Place pillows or foam wedges between two bony surfaces
Keep the patient’s skin directly off plastic surfaces
Help the patient maintain an adequate intake of protein and calories and a fluid intake of 2 – 3L/day

Perform a daily inspection of the patient’s entire skin and document all sores and signs of infection
Use moisturizers daily on dry skin, and apply when skin is damp
Keep moisture from prolonged contact with skin
Keep areas dry where two skin surfaces touch, such as the axillae and under the breasts
Place absorbent pads under areas where perspiration collects
Use moisture barriers on skin areas where wound drainage or incontinence occurs
Clean the skin as soon as possible after soiling occurs and at routine intervals
Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence with tepid rather than hot water
While cleaning, use the minimum scrubbing force necessary to remove soil and gently pat dry

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32
Q

passive wound dressing

A

have only a protective function and maintain a moist environment for natural healing; they just cover that area and may remain in place for several days
DuoDERM, Tegaderm

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33
Q

interactive wound dressing

A

capable of absorbing wound exudate while maintaining a moist environment in the area of the wound and allowing the surrounding skin to remain dry
Hydrocolloids, alginates, hydrogels

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34
Q

active wound dressings

A

improve the healing process and decrease healing time
Skin grafts, biologic skin substitutes

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35
Q

Surgical management of a pressure ulcer includes

A

removal of necrotic tissue and skin grafting or use of muscle flaps to close wounds that do not heal by re-epithelialization and contraction
Those with poor blood flow are unlikely to have successful graft take and heal
The procedures are very similar to the surgical management of burn wounds

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36
Q

Negative pressure wound therapy

A

can reduce or even close chronic ulcers by removing fluids or infectious materials from the wound and enhancing granulation
This technique requires that a suction tube be covered by a special sponge and sealed in place
Per manufacturer’s instructions, the foam dressing is changed every 48 to 72 hours (or at least 3 times weekly). Continuous low-level negative pressure is applied through the suction tube
Duration of the treatment is determined by the wound’s response

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37
Q

Impetigo

A

Characterized by red macules that become thin-walled vesicles that rupture and become covered with honey-yellow crust
May have formation of bullae (large fluid-filled blisters) from original vesicles, then the bullae rupture leaving red raw areas
Exposed areas of the body, face, hands, neck and extremities are most frequently involved
Contagious and may spread to over parts of the body or to other people

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38
Q

Folliculitis

A

Isolated erythematous pustules occur singly or in groups; hairs grow from centers of many of the lesions
Occasional papules are present
There is little or no associated discomfort
There is no residual scarring
Areas of hair-bearing skin, especially areas of shaving, thighs, buttocks, and axillae are affected

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39
Q

Furuncle (boil)

A

Small, tender, erythematous nodules become pus filled
Lesions may be single or multiple and also recurrent
May progress and involve the skin and subcutaneous fatty tissue, causing tenderness, pain, and cellulitis
Occasional scarring results

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40
Q

Cellulitis

A

Localized area of inflammation may enlarge rapidly if not treated
Redness, warmth, edema, tenderness, and pain are present
On rare occasions, blisters are present
Cellulitis is often accompanied by lymphadenopathy and fever
Lower legs, areas of persistent lymphedema, and areas of skin trauma (e.g., leg ulcer, puncture wound) are affected

41
Q

Herpes zoster (varicella zoster)

A

Lesions are similar in appearance to herpes simplex and also progress with weeping and crusting
Grouped lesions present unilaterally along a segment of skin following the pathway of a spinal or cranial nerve (dermatomal distribution)
Eruption is preceded by deep pain and itching
Postherpetic neuralgia is common in older adults
Areas of the anterior or posterior trunk following the involved dermatome; face, sometimes involving trigeminal nerve and eye are affected

42
Q

Herpes simplex

A

Grouped vesicles are present on an erythematous base
Vesicles evolve to pustules, which rupture, weep, and crust
Older lesions may appear as punched-out, shallow erosions with well-defined borders
Lesions are associated with itching, stinging, burning or pain
Type 1 classically occurs on the face and type 2 on the genitalia, but either may develop in any area where inoculation has occurred

43
Q

Candidiasis

A

The erythematous macular eruption occurs with isolated pustules or papules at the border (satellite lesions)
Candidiasis is associated with burning and itching
Oral lesions (thrush) appear as creamy white plaques on an inflamed mucous membrane
Cracks or fissures at the corners of the mouth may be present
Skinfold areas: perineal and perianal region, axillae, beneath breasts, and between the fingers; under wet or occlusive dressings can all be affected along with the oral or vaginal mucous membranes

44
Q

Pediculosis (lice) S/S

A

Pediculosis capitis(head lice)
Pediculosis corporis(body lice)
Pediculosis pubis(pubic, or crab, lice)

Pruritus and excoriation from scratching
Matting and crusting of the scalp and a foul odor indicate a probable secondaryinfection

45
Q

Scabies

A

A contagious skininfectioncaused by mite infestations, transmitted by close contact with an infested person or infested bedding

46
Q

scabies S/S

A

Intense itching
Red pruritic eruptions
Small raised burrows created by the mites
Usually affects between the fingers, wrists, elbows, knees, edges of feet, axillary folds, under breasts, near the groin, or penis / scrotal areas

47
Q

Bedbugs

A

This parasite does not live on humans; however, it feeds on human blood
The insect bites a human host at night and sucks blood for 3 to 10 minutes
The bite area resembles a mosquito or flea bite with a raised bite mark surrounded by a wheat

48
Q

bedbugs S/S

A

The bite causes an itchy discomfort
Clustered bite marks

49
Q

Psoriasis

A

is a chronic, autoimmune disorder that results from overstimulation of the immune system (Langerhans’ cells) in the skin that target keratinocytes, causing increased cell division (because some degree ofcellular regulationis lost) and plaque formation
Chronic condition with exacerbations and remissions

50
Q

psoriasis S/S

A

Reddened papules or plaques covered by silvery white scales
Bilateral distribution
Borders between the lesions and normal skin are sharply defined
Lesions thicken during exacerbations and extend to new body areas

51
Q

psoriasis nursing interventions

A

Nonpharmacological
Urge patients and families to consider support groups
Pharmacological
Topical steroids
Phototherapy / ultraviolet light
Systemic biologic & immunomodulating agents

52
Q

skin cancer

A

occurs as a result of failure ofcellular regulationover cell division
Current estimates are that one in five Americans will develop skin cancer in their lifetime
It is estimated that approximately 9,500 people in the U.S. are diagnosed with skin cancer every day
Basal cell and squamous cell carcinomas, the two most common forms of skin cancer, are highly curable if detected early and treated properly
Five-year survival rates for regional and distant stage melanomas are 63 percent and20 percent, respectively

53
Q

Actinic keratosis (premalignant)
distribution and course

A

Cheeks, temples, forehead, ears, neck, backs of hands, and forearms

May disappear spontaneously or reappear after treatment; slow progression to squamous cell carcinoma is possible

54
Q

Actinic keratosis (premalignant) S/S

A

Small (1-10 mm) macule or papule with dry, rough, adherent yellow or brown scale
Base may be erythematous
Associated with yellow, wrinkled, weather-beaten skin
Thick, indurated keratoses more likely to be malignant

55
Q

Basal cell carcinoma distribution and course

A

Sun-exposed areas, especially head, neck, and central portion of face

Metastasis is rare; may cause local tissue destruction; 50% recurrence rate related to inadequate treatment

56
Q

Basal cell carcinoma S/S

A

Pearly papule with a central crater and rolled, waxy borders
Telangiectasias and pigment flecks visible on close inspection
As it grows, it undergoes central ulceration and sometimes crusting

57
Q

squamous cell carcinoma distribution and course

A

Sun-exposed areas, especially head, neck, ears, nose and lower lip; sites of chronic irritation or injury (e.g., scars, irradiated skin, burns, leg ulcers)

Rapid invasion with metastasis via the lymphatics occurs in 10% of cases; larger tumors are more prone to metastasis

58
Q

spuamous cell carcinoma S/S

A

Rough, thickened, scaly tumor (may involve bleeding)
Indurated margins
Fixation to underlying tissue with deep invasion

59
Q

melanoma distribution and course

A

Can occur anywhere on the body, especially where nevi (moles) or birthmarks are evident; commonly found on upper back and lower legs; soles of feet and palms in dark-skinned people

Radial growth phase followed by vertical growth phase; rapid invasion and metastasis with high morbidity and mortality

60
Q

melanoma S/S

A

Irregularly shaped, pigmented papule or plaque
Variegated colors, with red, white, and blue tones

61
Q

Assess for ABCDE features that are associated with skin cancer:

A

A: asymmetry of shape
B: border irregularity
C: color variation within one lesion
D: diameter greater than 6mm
E: evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

62
Q

Prevention techniques for skin cancer

A

Avoid sun exposure between 11am and 3pm
Use sunscreen with the appropriate skin protection factor for your skin type
Wear a hat, opaque clothing, and sunglasses when you are out in the sun
Keep a “body map” of your skin spots, scars, and lesions to detect when changes have occurred
Examine your body monthly for possibly cancerous or precancerous lesions
Seek medical advice if you note any of the ABCDE changes

63
Q

skin cancer nursing interventions

A

Nonsurgical management
Topical or systemic chemotherapy, biotherapy or targeted therapy
Radiation therapy
Surgical management
Cryosurgery
Curettage and electrodesiccation
Excisional biopsy
Mohs’ surgery
Wide excision

64
Q

The tissue destruction

A

caused by a burn injury leads to local and systemic problems that affect:
Fluid and electrolyte balance
Protein losses
Sepsis development
Changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning

65
Q

Superficial-thickness wounds

A

Have the least damage because the epidermis is the only part of the skin that is injured

66
Q

Superficial-thickness wounds S/S

A

Redness,pain, tingling and increased sensitivity to heat occurs as a result; desquamation(peeling of dead skin) occurs 2 to 3 days after the burn

67
Q

superficial-thickness wounds heals…

A

rapidly in 3 to 6 days without a scar or other complication

68
Q

Superficial partial-thickness wounds

A

Caused by injury to the upper third of the dermis, leaving a good blood supply
The small vessels bringing blood to this area are injured, resulting in the leakage of large amounts of plasma, which in turn lifts the heat-destroyed epidermis, causing blister formation

69
Q

Superficial partial-thickness wounds S/S

A

Pink to red, painful, blisters

70
Q

Superficial partial-thickness wounds heals in…

A

10 to 21 days with no scar, but some minor pigment changes may occur

71
Q

Deep partial-thickness wounds

A

Extend deeper into the skin dermis, and fewer healthy cells remain
Blisters usually do notform because the dead tissue layer is thick, sticks to the underlying dermis, and does not readily lift off the surface

72
Q

Deep partial-thickness wounds S/S

A

Red and dry with white areas in deeper parts (dry because fewer blood vessels are patent) with moderate edema

73
Q

Deep partial-thickness wounds heals in…

A

2 to 6 weeks, but scar formation results

74
Q

Full-thickness wounds

A

Destruction of the entire epidermis and dermis, leaving no skin cells to repopulate
This wound does not regrow, and areas not closed by wound contraction require grafting

75
Q

Full-thickness wounds S/S

A

Hard, dry, leatheryeschar forms from coagulated particles of destroyed skin; with severe edema
May be waxy white, deep red, yellow, brown, or black

76
Q

Full-thickness wounds healing time

A

can range from weeks to months depending on establishing a good blood supply

77
Q

Deep full-thickness wounds

A

Extend beyond the skin and damages muscle, bone, and tendons
All full-thickness burns need early excision and grafting

78
Q

Deep full-thickness wounds S/S

A

Charred, blackened and depressed, with sensation completely absent

79
Q

Deep full-thickness wounds healing?

A

Grafting may not be successful. Amputation may be needed when an extremity is involved

80
Q

Vascular changes resulting from burn injuries

A

Circulation to the burned skin is disrupted immediately after injury by blood vessel occlusion
Fluid shiftoccurs after initial vasoconstriction as a result of blood vessels near the burn dilating and leakingfluidsinto the interstitial space
Leakage of fluid and electrolytes from the vascular space continues, causing extensive edema, even in areas that were not burned, leading to weight gain
Hypovolemia, metabolic acidosis,hyperkalemia, andhyponatremia occur in the first 24-36 hours
Fluid remobilizationstarts at about 24 hours after injury, when the capillary leak stops. The diuretic stage begins at about 48 to 72 hours after the burn injury

81
Q

For patients in the emergent/resuscitative phase

A

nurses should do a primary survey and monitor circulation. As the taut, burned tissue becomes unyielding to the edema underneath its surface, it begins to act like a tourniquet, especially if the burn is circumferential. As edema increases, pressure on small blood vessels in the distal extremities causes an obstruction of blood flow and consequent tissue ischemia and compartment syndrome

82
Q

Pulmonary changes resulting from burn injuries

A

Respiratory problems are caused by superheated air, steam, toxic fumes, or smoke
Respiratory damage from an inhalation injury can occur in the upper and major airways and the lung tissue and can cause edema that leads to obstruction
The lining of the trachea and bronchi may slough 48 to 72 hours after injury and obstruct the lower airways
Leaking capillaries cause alveolar edema, which can occur immediately or up to a week after the injury

83
Q

Cardiac changes resulting from burn injuries

A

Heart rate increases and cardiac output decreases because of the initial fluid shifts and hypovolemia that occur after a burn injury
Workload of the heart and oxygen demands increase with decreased perfusion, oxygen delivery and BP  shock
Cardiac output may remain low until 18 to 36 hours after the burn injury
Cardiac output improves with fluid resuscitation and reaches normal levels before plasma volume is restored completely
Proper fluid resuscitation and support with oxygen prevent further complications

84
Q

Gastrointestinal and renal changes resulting from burn injuries

A

The sympathetic nervous system stress response increases secretion of epinephrine and norepinephrine, which inhibit GI motility and further reduce blood flow to the area
Secretions and gases collect in the GI tract, causing abdominal distention
Peristalsis decreases, and a paralytic ileus may develop
The increased production (and loss) of heat breaks down protein and fat(catabolism),rapidly uses glucose and calories, and increases the metabolic rate and calorie needs
If there is inadequate blood flow, acute kidney injury can occur

85
Q

Age related changes increasing complications from burn injuries

A

Thinner skin, sensory impairment, decreased mobility
Slower healing time
More likely to have cardiac impairments
Reduced inflammatory and immune responses
Reduced thoracic and pulmonary compliance
More likely to have pre-existing medical conditions such as diabetes mellitus, kidney impairment, or pulmonary impairment

86
Q

Emergency management of burn

A

Assess the airway for patency
Administer oxygen as needed
Cover the patient with a blanket and cover the wound with a clean dry cloth
Keep the patient on NPO status
Elevate the extremities if no fractures are obvious
Obtain vital signs
Initiate an IV line and begin fluid replacement
Administer tetanus toxoid for prophylaxis
Perform a head-to-toe assessment

87
Q

Respiratory assessment
inspection for burns

A

Inspect the mouth, nose, and pharynx
Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present
Burns inside the mouth and singed nasal hairs also indicate possible inhalation injury
Black particles of carbon in the nose, mouth, and sputum; edema of the nasal septum; and a “smoky” smell to the patient’s breath indicate smoke inhalation

88
Q

respiratory assessment for burns signs and symptoms

A

Progressive hoarseness or brassy cough; drool or difficulty swallowing; audible wheezing, crowing or stridor, dyspnea in supine position

89
Q

Cardiovascular assessment for burns

A

Changes in the cardiovascular system begin immediately after the burn injury and include shock as a result of disruptedfluid and electrolyte balance
At first, cardiac manifestations are from hypovolemia and decreased cardiac output
Monitor the degree of edema, and assess cardiac status by measuring central and peripheral pulses, blood pressure, capillary refill, and pulse oximetry
Obtain baseline ECG tracings at the time of admission, and continue the ECG monitoring throughout the resuscitation phase

90
Q

Gastrointestinal assessment
for burns

A

Although the GI tract usually is not directly injured, changes in function occur in all burn patients
The decreased blood flow and sympathetic stimulation reduce GI motility and promote development of a paralytic ileus
Bowel sounds are usually reduced or absent in a patient with severe burns; nausea, vomiting, and abdominal distention may also be present if there is an ileus
Patients with burns of 25% TBSA or who are intubated generally require a nasogastric (NG) tube inserted to prevent aspiration and remove gastric secretions

91
Q

Genitourinary assessment for burns

A

Changes in kidney function with burn injury are related to decreased blood flow and cellular debris. During the fluid shift, blood flow to the kidney may not be adequate for filtration
When muscle damage occurs from a major burn or electrical injury,myoglobinis released from damaged muscle and circulates to the kidney, along with other proteins from damaged blood cells; which can contribute and cause kidney failure
Assess kidney function and monitor intake and urine output hourly

92
Q

Nursing interventions related to respiratory issues

A

Nonsurgical management
Airway maintenance
Promotion of ventilation, gas exchange and oxygen therapy
Drug therapy
Positioning and deep breathing
Surgical management
Tracheostomy
Escharotomy
Chest tubes

93
Q

Nursing interventions related to cardiovascular issues

A

Nonpharmacological
Priority nursing interventions are carrying out fluid resuscitation and monitoring for indications of effectiveness or complications
Monitor any invasive cardiac monitoring devices
Pharmacological
IV fluid resuscitation
Drug therapy
Surgical
Escharotomy

94
Q

Fluid resuscitation (The Parkland Formula)

A

Initiate and maintain at least one large-bore IV in an area of intact skin (if possible)
Coordinate with physicians to determine the appropriate fluid type and total volume to be infused during the first 24 hours postburn
Administer one half of the total 24-hour prescribed volume within the first 8 hours postburn and the remaining volume over the next 16 hours
2mL NS or LR x patients weight in kg x % TBSA
Assess IV access site, infusion rate, and infused volume at least hourly
Monitor vital signs at least hourly
Assess for fluid overload
Measure and assess strict intake and output at least hourly

95
Q

Nursing interventions related to pain

A

Nonsurgical
Drug therapy with analgesics and opioids
Complementary therapy
Environmental manipulation
Surgical
Early excision

96
Q

The acute phase of burn injury begins

A

about 36 to 48 hours after injury, when the fluid shift resolves, and lasts until wound closure is complete

97
Q

During this phase, the nurse coordinates interdisciplinary care that is directed toward continued assessment and maintenance of the:

A

Cardiovascular and respiratory systems
GI andnutritionstatus
Burn wound care and infection control
Paincontrol
Musculoskeletal contractions and promoting mobility
Psychosocial interventions

98
Q

acute phase of burn injuries nursing interventions

A

Provide a safe environment
Use of asepsis, ensure daily cleaning of the room and unit
Do not share equipment among patients; use disposable items as much as possible
Detect problems early
Continually assess and monitor these patients carefully
Perform dressing changes as ordered
Avoid musculoskeletal problems, such as contractions, with proper positioning
Ensure adequate diet and fluids
Tetanus prophylaxis given

99
Q

Although rehabilitation efforts are started at the time of admission, the technical rehabilitative phase begins with wound closure and ends when the patient achieves his or her highest level of functioning
The emphasis is on:

A

The psychosocial adjustment of the patient
The prevention of scars and contractures
The resumption of preburn activity, including resuming work, family, and social roles
This phase may take years or even last a lifetime as patients adjust to permanent limitations

Med-Surge 2 Exam 2 (4 decks)

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