INTEGUMENTAR

Y SYSTEM
Integumentary
System
• Largest body organ
• Skin
• Hair
• Nails
• Glands
 Integumentary System
• Epidermis
• Outermost layer of
the skin
• Dermis
• Contains collagen
• Supports nerve and
vascular network
• Subcutaneous
• Fat and loose
connective tissue
 • Epidermis:
Structure • Thin avascular,
superficial layer
• Nourished blood
vessels (dermis)
• Replaced every 28
days
• Types of cells:
• Melanocytes
• keratinocytes
 Structure
• Melanocytes:
• Deep, basal layer
• Melanin
• Keratinocytes:
• Produce keratin:
• Stratum corneum
 Structure
• Dermis
• Highly vascular
• Nerves, lymphatic
vessels, hair
follicles,
sebaceous glands
Structure
• Subcutaneous tissue
• Beneath dermis, adipose
tissue
• Provides insulation
Skin Appendages
• Hair:
• Except: lips,
palms, soles

• Nails:
• Grows from
matrix
Appendages
• Hair
• Primarily dead cells
• Hair root begins in bulb
of hair follicle and
grows from dermis
upward
• Typical loss: 50-100
hairs/day
• Melanocytes on bulb
determine color
• Attached to Arrector pili
muscles
• Glands:
• Sebaceous (oil glands)
• Sebum:
• lubricates skin, decrease water
loss
• aid in killing bacteria on skin
surface
• Apocrine sweat glands
• Located in the axilla, anus, genital
area
• Function: unknown
• Eccrine Sweat glands
• Sweat glands located on forehead,
hands, soles of feet
• Maintain a stable temp for body
(perspiration) when body is
overheated
Integumentary
System
• Functions:
• Protect underlying
tissue of body
• Barrier against
bacteria, virus,
excessive water
loss
• Sensory perception
• Synthesis of Vit D
• Esthetic function
• Absorption
ASSESSMENT of
INTEGUMENTARY SYSTEM
• Health History
1. Presenting problem:
symptoms may include changes in
color or texture of skin, hair, nails;
pruritus;
infections;
tumors;
lesions;
dermatitis;
ecchymoses;
rashes;
dryness
 Health
Histor
y

2. Life-style:
hygienic practices (skin-cleansing
measures, use of cosmetics [type,
brand names]);
skin exposure (duration of
exposure to sun, irritants
[occupational], cold weather)

3. Nutrition/diet:
intake of vitamins,
essential nutrients,
water;
food allergies
 Health History
4. Use of medications:
steroids,
vitamin use,
hormones,
antibiotics,
chemotherapeutic
agents

5. Past medical history:

renal, hepatic, or
collagen diseases;
trauma or surgery;
food, drug, or contact
allergies
Health History
6. Family history:
diabetes mellitus,
allergic disorders,
blood dyscrasias,
specific dermatologic problems,
cancer
Physical Assessment
• Inspection
• Color and pigmentation,
vascularity, bruising
• Lesions or discolorations
• Palpation
• Temp, turgor, moisture,
texture
Abnormalities
• Alopecia
• Loss of hair

• Carotenemia
• Yellow discoloration (palms,soles)
Abnormalities
• Jaundice
• Yellowish discoloration of
skin
• Sclera

• Cyanosis
• Bluish-gray, dark purple
discoloratrion
• Petechiae
• Pinpoint deposit of
blood (1-2 mm)

• Telangiectasia/spider
angioma
• Dilated, superficial,
small blood vessels
 • Erythema
• Redness in patches
of variable size/shape
• Ecchymosis
• Large, bluish like
lesion
ERYTHEMA
• Hematoma
• Extravasation of
blood with swelling

ECCHYMOSIS

HEMATOMA
 Assessment
Abnormalities
• Tenting
• Failure of skin to return
immediately after gentle
pinch

• Varicosity
• Increased prominence of
superficial veins
 Assessment
• Hirsutism
• Male distribution of
hair (women)

• Mole
• Benign overgrowth of
melanocytes
 Physical Assessment

• Comedo
• Enlarged hair follicle plugged with sebum,
bacteria, skin cells (keratin)
• Closed: whitehead
• Open: blackhead
 NAMES OF COMMONLY SEEN
LESIONS
• Primary lesions • Secondary lesions
are those originally result from some
produced by trauma or alteration, usually
other stimulation: traumatic, to the
• Macule primary lesion.
• patch • scales
• Papule • crusts
• Plaque • excoriation
• Nodule • erosion
• Tumor • ulcer
• cyst • fissure
• vesicle or blister • scar
• bullae • lichenification
• pustule
• wheal
• petechiae
PRIMARY SKIN LESIONS
are those originally
produced by trauma or other
stimulation:
• Macule
• patch
• Papule
• Plaque
• Nodule
• Tumor
• cyst
• vesicle or blister
• bullae
• pustule
• wheal
• petechiae
Primary Lesions • Macule
(Non-palpable) • Flat, nonpalpable,
circumscribed
• less than 1 cm
• Ex: freckle

• Patch
• Flat, non-palpable
• Irregular shape
• Greater than 1 cm in
diameter
• vitiligo
 Primary
Lesion
• Papule
• Elevated, palpable, firm,
circumscribed
• Less than 1 cm
• Wart, nevi

• Plaque
• Elevated, firm
• Greater than 1 cm in diameter
• psoriasis
 Primary Lesions
• Nodule
• Solid elevated, circumscribed with
palpable deeper portion to dermis
• 1-2 cm in diameter
• Lipomas

• Tumor
• Solid, elevated with palpable deeper
portion greater than 2 cm

• Cyst
• Raised lesion with sac containing solid
material
• Sebaceous cysts
 • Wheal
Primary
• Edematous round or
Lesions flat topped
• Disappears within
hours
• Insect bite
 PRIMARY LESIONS
(fluid-filled)
• Vesicle
• Elevated, circumscribed
• Filled with serous fluid
• Less than 1 cm
• Blister (chickenpox)
• Bulla:
• Vesicle greater than 1
cm
• 2nd degree burn
 Primary lesion (Fluid-filled)

• Pustule
• Similar to vesicle but
with purulent fluid
• Acne, impetigo
 SECONDARY SKIN LESIONS
SCALES CRUSTS • scales
• crusts
• excoriation
• erosion
FISSURE • ulcer
• fissure
• scar
• lichenification
EROSION

EXCORIATION LICHENIFICATION
ULCERATION
SECONDARY SKIN LESIONS

• Erosion
• Loss of epidermis
• Surface is moist but does not bleed
• Moist area after the rupture of vesicle

• Ulcer
• Loss of epidermis and dermis
• Irregular shape

• Fissure
• Linear crack in the epidermis that extend to dermis
• Chapped hands, lips
• Athlete’s foot
Secondary Lesions
• Scales
• Heaped-up keratinized cells
• Flaky exfoliation, irregular
• Thick or thin
• Psoriasis

• Crust
• Dried serum,bld,purulent
exudate
• Slightly elevated
• Scab on abrasion
 Secondary
Lesions
• Lichenification
• Thickening and roughening of
the skin
• Caused by rubbing, irritation
• Chronic dermatitis

• Atrophy
• Thinning of the skin with
loss of normal skin furrows
• Skin looks shinier and more
translucent than normal
• Arterial insufficiency
• Excoriation
• An abrasion or scratch mark.
• May be linear, or rounded as in a
scratched insect bite

• Scar
• Thin fibrous tissue replacing
injured dermis, irregular

• Keloid
• Irregular, elevated
• Progressively enlarging scar
• Grows beyond boundaries of wound
 Diagnostic tests
• Biopsy
• Sterile field, local
anesthesia
• Cover biopsy site,
control bleed
• Shave: superficial lesion;
scalpel
• Punch: stretch tight, punch
pressed into dermal skin
• Incisional:
• Excisional:
INCISIONAL
BIOPSY
Nursing care: instruct client to
EXCISIONAL keep biopsied area dry until
BIOPSY healing occurs
 Diagnostic tests
• Cultures and Sensitivity:
• Bacterial: exudate from lesion
• Viral: lesion unroofed, floor of lesion is scraped
• Fungal: area brushed with cytology brush
• Culturette sterile swab and tube
• Place swab in tube. Crush bottom of tube
• Label, send to lab
 Diagnostic Studies
• Scrapings:

• Fungal: scraping from edge of lesions (scales, hair, nails) placed on slide
• 10 – 20% KOH added, examined microscope

• Infestations: Mineral oil scraping

• Mineral oil applied to lesion
• Scrape off top of lesion/burrow with scalpel blade
• Glass slide, microscope for mites, eggs, fecal material
 Diagnostic Tests

• Tzank test (Wright’s and Geimsa’ stain)

• Fluid and cells from vesicles
• Slide and stained
• Examined microscope
 Microscopic Tests

• Wood’s lamp (Black light)

• Examination of skin with long-wave
ultraviolet light
• Causes substances to fluoresce
• Detect fungal infection, pseudomonas org
 1. Skin testing
Diagnostic tests Administration of allergens or
antigens on the surface of or into the
dermis to determine hypersensitivity

• Scratch test: tine or prick test

• Allergen applied to
superficial skin scratch

• Patch Test
• Antigen applied to skin and
covered with gauze
• Removal of allergens after
48 hrs

• Intradermal test
• Injection small amt of
allergen into intradermal
layer
 Diagnostic test

• Interpreting results:
• Positive reaction:
• Erythema and wheal (15-20 min)
• Previous exposure

• Negative:
• antibodies have not formed yet
Bacterial Infections
• Impetigo
• Folliculitis
• Furuncle
• Carbuncle
• Cellulitis
Impetigo • Group A B-hemolytic
streptococci, staphylococcal
infection
• Poor hygiene,low
socioeconomic status
• Contagious, Common on
face
• Untreated:
glomerulonephritis

• Assessment:
• Vesiculopustular lesions
• honey-colored crust
• Erythema, Pruritic
Impetigo • Mx:
• Local: topical oint
• Gentle washing 2-3 X/day:
crust removal
• Soap and water
• Topical antibiotic
(Bactroban) cream
• Systemic antibiotic: extensive
and facial lesions
• Oral penicillin,
erythromycin
• Take full course
• Bath daily, bactericidal soap,
ind towel/washcloth
• Good hand washing
 • Inflammation of one/more hair follicles
Folliculitis (Pimple) • Staphyloccocus aureus
• In areas subjected to friction, moisture, or oil
• Common on scalp, beard, extremities
• Increased incidence in patients with DM

• Assessment:
• Small pustule at hair follice, erythema,
crusting
• Tender to touch

• Mx:
• Antistaphylococcal soap (Hibiclens, dial) and
water
• Warm compress of water or aluminum acetate
solution
• Topical (Bactroban), systemic antibiotic
 • Deep infection with staphyloccoci
Furuncle around hair follicle
(boil) • Common: face, back of neck, axillae,
breast, buttocks, perineum, thigh

• Furunculosis
• Malaise, elevated body
temperature
• Regional lymph nodes
enlargement
• Assessment:
• Tender erythematous area around hair follicle
• Draining pus and necrotic debris on rupture
• Painful

• Mx:
• I and D with packing
• Antibiotics
 Carbuncle
(Multiple boils)
• Multiple, inteconnecting
furuncles
• Common: nape

• Assessment:
• Many pustules
appearing in
erythematous area

• Mx:
• I and D
• Antibiotics
 Cellulitis
• Inflammation subcutaneous tissues
• Cause: S. Aureus and streptococci

• Assessment:
• Hot, tender, erythematous,
edematous area
• Chills, malaise, fever

• Mx:
• Systemic Antibiotics
(Penicillin)
• Moist heat, immobilization
and elevation
 Erysipelas
• Superficial cellulitis involving the dermis
• Group A B-hemolytic strepcococci
• Common: face, extremitis

• Assessment:
• Red, swollen, warm, hard, painful
rash
• Fever, elevated WBC, headache,
malaise

• Mx:
• Systemic antibioitc
Fungal Infections
• Candidiasis
• Tinea
• Tinea corporis
• Tinea cruris
• Tinea Pedis
• Tinea unguium (Onychomycosis)
Candidiasis (Moniliasis)
• Caused by Candida Albicans
• Warm, moist area: groin, oral
mucosa

• Mouth:
• White cheesy plaque
(milk curds)
• Does not come off with
rubbing
 Candidiasis
• Vagina:
• Vaginitis with red,
edematous, painful
vaginal wall white
patches,
• Vaginal discharge,
pruritus
• Pain on urination and
intercourse
• Skin:
• papular erythematous
rash with pinpoint
satellite lesions around
edges

• Mx:
• Nystatin (suppository,
lonzenge, powder)
• Use of condom
• Keep clean and dry
 Tinea
(Ringworm)
• Tinea Corporis
• Ring-like scaly
appearance
• Erythematous

• Tine Cruris (Jock itch)

• Scaly plaque in groin area
• Tinea Pedis (Athlete’s foot)
• Interdigital scaling
• Pruritic, painful

• Tinea Unguium
(Onychomycosis)
• Toenails
• Thickened, broken nail
with yellowish
discoloration, scale
under nail
Tinea
Mx:
• Topical antifungals: clotrimazole
(Lotrimin)
• Nail removal (avulsion): option
Common Infestations:
• Pediculosis
• Scabies
 PEDICULOSIS
• Pediculus humanus capitis (head)
• Sharing contaminated
head coverings/
hairbrushes)

• Pediculus humanus corporis

(body)
• Close contact:

• Phthirus pubis (pubic/crab louse)

• Sexual contact
PEDICULOSIS
• Female:
• lays eggs (nits-white,
oval) hair shaft
• Live lice: grayish
white, wingless
insect
• Assessment:
• Itching, skin irritation
Pediculosis
• Management:
• Permethrin 1% (Nix): shampoo
• Clean, slightly damp
hair
• Leave 10 mins, rinse
thoroughly
• Fine-toothed comb
• Bedding/clothing: hot water
laundry,hot dried (20 min)
• Non-washable: dry-cleaned or
plastic bags for 2 wks
 Scabies
• Sarcoptes Scabies
• Female burrows under skin:
lay eggs
• Transmission: direct contact

• Assessment:
• Intense itching (worse at night): folds
• Burrows bet fingers, wrists, axillary
folds
• Redness, swelling
 SCABIES

• Mx:
• Permethrin 5% topical lotion (Eliminate):
• Applied to skin head to soles of feet: 8-14 hrs,
then washed
• 2nd application after 1 wk later
• Sulphur/special soaps
• Launder all clothes/linen: bleach
• Antibiotic: secondary infection
Common Benign Conditions
• Skin tags
• Vitiligo
• Lentigo
• Acne
• Psoriasis
Acrochordons

• Skin Tags

• Small, skin-colored, soft,

pedunculated papules

• Mx:
• Cryotherapy, cautery
 Vitiligo

• Cause unknown
• Genetic, precipitated by
crisis
• Complete absence of
melanocytes,
noncontagious
• Assessment:
• Symmetric, may be
permanent
• Mx:
• Topical steroids
• Psoralen with UVA
Lentigo
• Increased melanocytes

• Assessment:
• Hyperpigmented
brown to black
macule/patch

• Mx:
• liquid nitrogen,
laser (may recur)
 Acne
• Chronic skin disorder caused by
inflammation of sebaceous glands
• Interplay of hormonal,
bacterial and genetic factors
• Assessment:
• Comedones
(blackheads/whiteheads)
• Papules and pustules

• Mx:
• Comedo extractor
• Topical : benzoyl peroxide, retinoids
• Systemic antibiotics
• Wash face 2X a day (antibacterial
soap)
• Use sparingly: cosmetics, creams,etc
Psoriasis • Chronic dermatitis
• Rapid turnover
epidermal cells
• Localized/general,
intermittent/continuous
• Unknown, Family
predisposition, triggered
stress

• Sharply demarcated
silvery scaling
plaques
• Scalp, elbows,
knees, palms,
soles, fingernails
Psoriasis • Mx:
• Topical: corticosteroids, tar
shampoo, anthralin
• Intralesion inj: corticosteroids
• Photochemotherapy: Psoralen
plus UVA lights (PUVA)
• 1/2 – 2 hrs; 2-3
times/week
• Goggles (cataract);
genitals (cover)
• Systemic: methotrexate

• Teaching:
• Avoid factors that worsen
itching
• Light cotton
bedding/clothes
• Hypoallergenic/glycerin
soap and tepid bath; pat dry
• Emotional support and
acceptance
 Verruca (Warts)
• Cause: human papillomavirus
• Transmission: direct contact, birth
canal
• Flesh-colored papules
• Types:
• Vulgaris: knees, elbows,
hands
• Subungual/periungual: around
and beneath nail beds
• Plantaris: feet
• Condyloma: genital warts
 • Mx:
Verruca (Warts)
• Chemical:
• Salicylic acid
• Tretinoin cream (Retin-
A): keratolytic
• Podohyllin and
trichlororcetic acid:
condyloma
• Cryotherapy: liquid
nitrogen
• Immunotherapy:
• Squaric acid: topical
solution
• Imiquimod (Aldara):
chondyloma
• Laser therapy
 • Viral infection that infects
Herpes Simplex mucosa of vagina, cervix
• HSV 1: Fever blister, cold
sore
• Contagious: direct
contact
• Excacerbated by stress,
sunlight, fatigue,
systemic infection
• corners of mouth, edge
nostrils
• Vesicles, erythematous
base
 Herpes Simplex
• HSV 2: genital herpes
• herpesvirus 11 (requires
darkness to survive)
• Incubation: 6 days
• vagina, cervix; penis
• Newborn maybe infected
during vaginal delivery
 Herpes Simplex
• Assessment:
• Headache, fever, swolen
inguinal lymph nodes
• Multiple vesicles, papules
• Small painful ulcers
• Erythema and edema
• Painful urination, vaginal
discharge
• Mx:No cure
• Acyclovir (Zovirax)
• Sedation (severe pain)
• Analgesics, topical
anesthetic, sitz bath
• No sex when lesion exist
 Herpes Zoster
(Shingles)

• Along pathway of peripheral nerves

• Cause: reactivation of varicella
zoster virus
• Immune suppressed, Had
chickenpox
• Contagious to those-- not had
chickenpox
• Pruritic, painful vesicles along
involved nerves
• Thoracic region
• Trigeminal nerve: face, scalp,
eyes
• Crusts, fever, malaise
Hepes Zoster (Shingles)

• Dx:
• Symptom history,
visual exam of
lesions
• Tzanck test, viral
culture

• Mx:
• Antiviral agents
• Acyclovir (Zovirax),
Vidarabine (Ara-A, Vir-A)
• Analgesics, antipruritics
 ECZEMA

• Inflammation of the
epidermis
• Types :
• Atopic dermatitis: Infantile
eczema
• hereditary (asthma,
allergic rhinitis)
• Red, oozing, crusty rash
• Elbow, knees, neck,
eyelids, hands
 • Contact dermatitis
Eczema • Allergic:
• Delayed
hypersensitivity
response to allergen
(poison ivy, nickel
(jewelry)
• Hrs to wks after
contact
• Irritant:
• Inflammatory
response to chemical
(solvent) irritant
(cleaning products,
fragrance, skin care
products)
 Eczema
• Xerotic dermatitis:
• severe dry, itchy, cracked skin
• Worsens in winter

• Seborrheic dermatitis: cradle cap

• Dry, greasy peeling of scalp
• Dx:
• Patch test
• Mx:
• Daily baths/shower
• Short. Avoid hot or very cold
• superfatted soap (Dove, neutrogena,
Aveeno, cetaphil)
• Aveeno (oatmeal) baths and topical
soaks
• Apply emollients (Aquaphor, eucerin,
cetaphil cream)
 • Topical steroids (apply
Eczema before emollient)
• Relieves inflammation
and itching
• Thin layer, 2 X/day
• Systemic
• Antibiotics,
Corticosteroids
• Antihistamines
• Keep room temp constant
• Cotton, loose clothing
• Keep nails short
Skin Cancer • Basal Cell
• Basal cell of the
epidermis
• Pearly white waxy
border, papule, red,
central crater
• Metastasis rare
• Squamous cell
• Tumor of keratinocytes
• Oozing, bleeding,
crusting lesion
• Potentially metastatic
• Melanoma
• ABCD
• Rapid metastasis
Skin Cancer • Risk Factors:
• Fair skin
• Dark skin: more
natural protection
• Family history
• Repeated exposure to
ultraviolet rays
• 11:00 Am and 3:00 PM
• Radiation exposure
• Long-term ulceration
• Treatment:
• Surgery
• Radiation
• Topical chemotherapy: 5-
fluorouracil
 Pressure Ulcer

• Decubitus ulcer, bedsore

• Occurs when capillary blood flow to the skin is occluded

as a result of prolonged pressure (immobility)
• Poor blood supply cause cells to die
 Pressure
Ulcer
• Stages:
• Stage1:
• Skin intact, non-
blanchable redness,
painful
• Involves only epidermis;
reversible if pressure is
relieved
• Stage 2:
• Abrasion, blister,
shallow crater,
painful
• Loss of dermis
Pressure Ulcer • Stage 3:
• Full-thickness skin
loss, deep crater
• Destruction into
subcutaneous
layer
• Not painful, foul
smelling with yellow
or green drainage
• Tunneling may or
may not be present
Pressure
Ulcer
• Stage 4:
• Damage extends
to the muscle,
tendon, bone
• Foul smelling
discharge
• Leathery black
crust: edges of
ulcer
• tunnelling
 Pressure Ulcer
• Common areas: bony
prominences
• Skull, elbows,
sacrum,coccyx, heels

• Prevention actions:
• Relieve pressure:
• Frequent changing of
position: Q 2 hrs
• Support surface to decrease
capillary pressure
• Eggcrate mattress, Air-
filled surfaces,
Floatation surface
• Sheepskin pads
 Pressure Ulcer

• Avoid shearing forces and friction:

• Trapeze bar: moving
• Turning sheet to pull patient up
• Keep skin dry and clean
• mild soap
• Provide optimal nutrition
• High protein, carbohydrates, Vit C
 Pressure ulcer

• Mx:
• Antibiotics
• Wound cleansing
• Chemical/Enzymatic Debridement: dissolves necrotic
tissue
• Collagenase (Santyl, Granulex), Elase, travase
• wet to dry dressing (NS)
• Pain management before removal
Applying Wet to Dry • Prepare client and remove
dressing
dressing • Forcep (soiled dressing
• If dressing adheres: do not
moisten, gently remove
• Observe dressing for amount,
characteristic of drainage
• Place fine-mesh gauze into
sterile basin and pour solution
• Sterile gloves
• Cleanse with antiseptic
solution/NS moving from least
to most contaminated areas
• Squeeze excess fluid
• Apply several dry, sterile gauze
• Secure dressings with tape
 Burn
• Tissue injury or necrosis
• Causes:
• Thermal:
flame,explosion,
scald injuries
• Chemical:
ingestion/contact
with
caustic/corrosive
chemicals
• Electrical: lightning,
electric current
• Radiation: sunburn,
radiation
• Inhalation : noxious
gases/heat
 Classification
• Partial thickness • Full thickness (third
• Superficial partial-thickness (first degree) and fourth degree)
• depth: epidermis only • Depth: all skin
• causes: sunburn, splashes of hot layers and nerve
liquid endings; may
• sensation: painful involve muscles,
•
tendons, and
characteristics: erythema, blanching
on pressure, no vesicles bones
• Deep partial thickness (second degree) • Causes: flame,
chemicals,
• depth: epidermis and dermis
scalding, electric
• causes: flash, scalding, or flame burn current
• sensation: very painful
• Sensation: little
• characteristics: fluid-filled vesicles; or no pain
red, shiny, wet after vesicles rupture
• Characteristics:
wound is dry,
white, leathery,
or hard
 BURN
• DEPTH:
• Superficial (first-degree)
• Erythema, mild swelling, no vesicles/blisters
• Painful, sensitive to touch
• Heals: 3-5 days
• Sunburn, low-intensity flash, brief scald
 • Partial-thickness (second
Burn degree):
• Epidermis and dermis
• Red, shiny vesicles,
edema
• Very painful, sensitive
to touch
• Heals: 21-28 days
• Scalds, flash flame
 BURN
• DEPTH:
• Full thickness (Third degree)
• Includes subcutaneous
layer and muscle
• Nerve endings, sweat
glands, hair follicles
destroyed
• Dry appearance, maybe
white of charred
• Variable pain, often severe
• Fire, contact with hot
object
• Healing: poor, requires
grafting
 Burn
• Full thickness (Fourth degree)
• Includes muscles, fascia,
bone
• Dull and dry, bone may be
exposed
 Burn

• Clinical Findings:
• Restlessness
• Pain (depends on degree)
• Cellular destruction:Hyponatremia,
hyperkalemia
• Hypovolemia: fluid shift
 BURN : Extent: Area affected
• Rule of Nines (Adults) • Lund and Browder (children & adult)
1. For children, the rule of nines is
modified; the head of a small
child is 18%-19%, the trunk
32%, each leg 15%, each arm
9 1/2%.

2. Burns in infants and toddlers

are frequently due to spills
(pulling hot fluids on them or
falling into hot baths);
baths for
older children, flame burns are
more frequent.
 BURN
• Severity
• Minor
• <10% TBSA
• No involvement of hands, face, genitalia
• OPD
• Moderate
• >10% - 20% TBSA
• hospital
• Major/Severe
• > 20% TBSA
• Specialized burn center
 STAGES
• Emergent phase
• Remove person from source of burn.
• thermal: smother burn beginning with the head.
• smoke inhalation: ensure patent airway.
• chemical: remove clothing that contains chemical; lavage
area with copious amounts of water.
• electrical: note victim position, identify entry/exit routes,
maintain airway.
• Wrap in dry, clean sheet or blanket to prevent further
contamination of wound and provide warmth.
• Assess how and when burn occurred.
• Provide IV route if possible.
• Transport immediately.
 STAGES
• Shock phase (first 24-48 hours)
• Plasma to interstitial fluid shift causing hypovolemia;
fluid also moves to areas that normally have little or
no fluid (third-spacing).
• Assessment findings
• dehydration, decreased blood pressure, elevated
pulse, decreased urine output, thirst
• diagnostic tests: hyperkalemia, hyponatremia,
elevated hct, metabolic acidosis
 STAGES
• Fluid remobilization or diuretic phase (2-5 days
postburn)
• Interstitial fluid returns to the vascular compartment.
• Assessment findings
• elevated blood pressure, increased urine output
• diagnostic tests: hypokalemia, hyponatremia,
metabolic acidosis
 STAGES
• Convalescent (Rehabilitation) phase
• Starts when diuresis is completed and wound healing
and coverage begin.
• Assessment findings
• dry, waxy-white appearance of full thickness burn
changing to dark brown; wet, shiny, and serous
exudate in partial thickness
• diagnostic test: hyponatremia
 Burn Management

• Emergent Phase: injury to 72 hrs

• Onset of injury through fluid resuscitation
• First Aid: Stop burn
• Flame: drop, log, roll; cool water; remove burned
clothing/jewelry
• Chemical: dust dry powder, flush with water
• Electrical: shut off, remove client
Medical management
• Supportive therapy: fluid management (IVs),
catheterization
• Wound care: hydrotherapy, debridement
(enzymatic or surgical)
• Drug therapy
• Topical antibiotics: mafenide (Sulfamylon),
silver sulfadiazine (Silvadene), silver
nitrate, povidone-iodine (Betadine)
solution
• Systemic antibiotics: gentamicin
• Tetanus toxoid or hyperimmune human
tetanus globulin (burn wound good
medium for anaerobic growth)
• Analgesics
• Surgery: excision and grafting
 Burn Managment

• Assess victim’s condition: ABC

• Assess smoke inhalation
• Client trapped in a closed space
• Hair in nostrils: singed
• Face, nose, lips: burned
• Blood: carboxyhemoglobin
• Mx: Elevate head of bed
 Burn Managment

• Cover burn: sterile or clean cloth

• Hypothermia, pain, contamination
• Transport:
• Fluid replacement:
• Brook (Modified): ¾ crystalloid plus ¼ colloid
• LR: 2 ml/kg/% TBSA
• Parkland (Baxter): LR only
• LR: 4 ml/kg/%TBSA
• ½: 8 hrs; ½ next 16 hrs
• Foley cath: 30 ml/hr
Nursing interventions
• Provide relief/control of pain.
• Administer morphine sulfate IV and
monitor vital signs closely.
• Administer analgesics/narcotics 30
minutes before wound care.
• Position burned areas in proper
alignment.
• Monitor alterations in fluid and
electrolyte balance.
• Assess for fluid shifts and electrolyte
alterations
• Administer IV fluids as ordered
• Monitor Foley catheter output hourly
(30 ml/hour desired).
• Weigh daily.
• Monitor circulation status regularly.
• Administer/monitor
crystalloids/colloids/H2O solutions.
• Promote maximal nutritional status.
• Monitor tube feedings/TPN if
ordered.
• When oral intake permitted, provide
high-calorie, high-protein, high-
carbohydrate diet with vitamin and
mineral supplements.
• Serve small portions.
• Schedule wound care and other
treatments at least 1 hour before
meals.
• Prevent wound infection.
• Place client in controlled sterile environment.
• Use hydrotherapy for no more than 30 minutes to prevent
electrolyte loss.
• Observe wound for separation of eschar and cellulitis.
• Apply mafenide (Sulfamylon) as ordered.
• administer analgesics 30 minutes before application.
• monitor acid-base status and renal function studies.
• provide daily tubbing for removal of previously
applied cream.
• Apply silver sulfadiazine (Silvadene) as ordered.
• administer analgesics 30 minutes before application.
• observe for and report hypersensitivity reactions
(rash, itching, burning sensation in unburned areas).
• store drug away from heat.
• Apply silver nitrate as ordered.
• handle carefully; solution leaves a gray or black stain
on skin, clothing, and utensils.
• administer analgesic before application.
• keep dressings wet with solution; dryness increases
the concentration and causes precipitation of silver
salts in the wound.
• Apply povidone-iodine (Betadine) solution as ordered.
• administer analgesics before application.
• assess for metabolic acidosis/renal function studies.
• Administer gentamicin as ordered: assess
vestibular/auditory and renal functions at regular
intervals.
• Prevent GI complications.
• Assess for signs and symptoms of paralytic
ileus.
• Assist with insertion of NG tube to
prevent/control Curling's/stress ulcer;
monitor patency/drainage.
• Administer prophylactic antacids through
NG tube and/or IV cimetidine (Tagamet) or
ranitidine (Zantac) (to prevent gastric pH of
less than 5).
• Monitor bowel sounds.
• Test stools for occult blood.
 • Provide client teaching and discharge planning concerning
• Care of healed burn wound
• assess daily for changes.
• wash hands frequently during dressing change.
• wash area with prescribed solution or mild soap and rinse well with
H2O; dry with clean towel.
• apply sterile dressing.
• Prevention of injury to burn wound
• avoid trauma to area.
• avoid use of fabric softeners or harsh detergents (might cause
irritation).
• avoid constrictive clothing over burn wound.
• Adherence to prescribed diet
• Importance of reporting formation of blisters, opening of healed area,
increased or foul-smelling drainage from wound, other signs of infection
• Methods of coping and resocialization
•
 TABLE 4.25 Guidelines and Formulas for Fluid
Replacement for Burns
Consensus Evans Formula Brooke Army Parkland/Baxter
Formula Formula Formula
Lactated 1. Colloids: 1 ml x wt. kg x % 1. Colloids: 0.5 ml x wt, Lactated Ringer's:
BSA burned kg x % BSA burned
Ringer's: 2-4 ml 2. Electrolytes (saline): 1 ml x 2. Electrolytes (lactated 4 ml x wt, kg x %
x wt. in kg x % wt. kg x % BSA burned Ringer's): 1.5 ml x wt, kg BSA burned.
body surface 3. Glucose (5% in water): x % BSA burned
2000 ml for insensible loss 3. Glucose (5% in water): Day 1: Half to be
area (BSA) Day 1: Half to be given in first2000 ml for insensible given in first 8
burned. Half to 8next
hrs; remaining half over
16 hrs.
loss
Day 1: Half to be given in
hours; half to be
be given in first Day 2: Half of previous day's first 8 hrs; remaining half given over next 16
8 hrs after burn; colloids and electrolytes; all over next 16 hrs. hours
of insensible fluid Day 2: Half of colloids,
remaining fluid replacement half of electrolytes, all of Day 2: Varies;
to be given over Maximum of 10,000 ml over insensible fluid colloid is added
24 hours. replacement
next 16 hrs. Second and third degree Second and third degree
burns exceeding 50% BSA burns exceeding 50%
calculated on basis of 50% BSA calculated on basis
BSA of 50% BSA.
 Computation
• 70kg patient with 50% TBSA burn;
• 50 kg with burn anterior chest, anterior lower extremities
• Brooke;
• Parkland
• Compute:
• ½: 8 hrs:
• Total ml infused:
• No of gtts/min
• ½: 16 hrs:
• Total ml:
• Ml/hr
• No of gtts/min
 Burn management

• Wound care
• Cleansing (shower, spray, tubbing with mild soap and
warm water), gentle debridement
• Strict aseptic technique
• Wound dressing
• Open: topical antimicrobial
• Silver sulfadiazine 1%(Silvadene, Flamazine)
• closed: antibiotic on dressing
• Silver-impregnated dressings (Acticoat, silverlon)
• Air/fluid bed, bed cradle
 Burn Management
• Tetanus immunization
• Tetanus toxoid:
• Tetanus globulin: not
immunized
• Meds:
• Pain: morphine sulfate IV
(No IM, Oral)
• Antibiotics, antacids, H2
block, sucralfate
 Burn Management

• Nutrition:
• NPO then clear liquids
• High protein, carbohydrates, v/m
 Burn Management

• Acute Phase: 3-5 days

• Start of diuresis (48-72 hrs) and ends with wound closure
• Wound care
• Cleansing
• Debridement (remove dead tissue)
• Mechanical: scissors/forceps
• Enzymatic: fibrinolytic enzyme
• Surgical: remove eschar (OR) to expose healthy tissue
 • Topical Antimicrobials
• Positioning:
Burn Management • Anticontracture positions: splints
• Physical therapy

SKIN GRAFT
Replacement of damaged skin with healthy
skin to provide protection of underlying
structures or to reconstruct areas for
cosmetic or functional purposes

• Skin graft: promote healing

• Heterograft (Xenograft)
• From animal
• Homograft (Allograft)
• Another person
• Autograft
• Client’s body
• Nursing care: preoperative
• Donor site: cleanse with antiseptic soap the night
before and morning of surgery as ordered.
ordered
• Recipient site: apply warm compresses and topical
antibiotics as ordered.
• Nursing care: postoperative
• Donor site
• Keep area covered for 24-48 hours.
hours
• Use bed cradle to prevent pressure and provide
greater air circulation
• Outer dressing may be removed 24-72 hours
postsurgery; maintain fine mesh gauze (innermost
dressing) until it falls off spontaneously.
• Trim loose edges of gauze as it loosens with
healing.
• Administer analgesics as ordered (more painful
than recipient site).
• Recipient site
• Elevate site when possible.
• Protect from pressure (use bed cradle).
cradle
• Apply warm compresses as ordered.
• Assess for hematoma, fluid accumulation under
graft.
• Monitor circulation distal to graft.
graft
• Provide emotional support and monitor behavioral
adjustments; refer for counseling if needed.
• Provide client teaching and discharge
planning concerning
• Applying lubricating lotion to
maintain moisture on surfaces of
healed graft for at least 6-12 months
• Protecting grafted skin from direct
sunlight for at least 6 months
• Protecting graft from physical injury
• Need to report changes in graft (fluid
accumulation, pain, hematoma)
• Possible alteration in pigmentation
and hair growth;
growth ability to sweat lost
in most grafts
• Sensations may or may not return
Burn Management
• Rehabilitation Phase:
• Wound closure to optimal level of
physical/psychological adjustment: 5 yrs
• Client gains independence and maximal
function
Thank You
