Integumentary System

NCM 104
CJ Cantos RN
The Skin

 As the external covering of the body, the

skin performs the vital function of protecting
internal body structures from harmful
microorganisms and substances.
Regions of the Skin

 Epidermis

 Dermis

 Hypodermis
 Epidermis
The epidermis is what type of tissue??
Keratinized stratified squamous epithelium

Thick skin has five layers Thin skin has four layers

Stratum corneum

Stratum lucidum

Stratum granulosum
Stratum spinosum
Stratum basale
 Layers of the Epidermis

 Stratum corneum
 Stratum lucidum
 Stratum granulosum
 Keratinization

 Cells still alive

 Stratum spinosum
 Epidermal dendritic cells

 Stratum basale (germinativum)

 Melanocytes

 Tactile Cells
 Cells of the Epidermis
 Keratinocytes

 Melanocytes

 Epidermal Dendritic Cells

(Langerhans Cells)

 Tactile Cells (Merkel Cells)

 A layer of squamous epithelial cells.
 Most of these cells produce a tough, fibrous
protein called keratin.
 The epidermis also produced specialized
cells called melanocytes. These produce
melanin (skin pigment). Aggregations of
melanocytes are nevi (moles and
birthmarks).
 Stratum corneum

Stratum lucidum

Stratum
Stratum
granulosum
spinosum

Stratum
basale
Dermis

 2 layers:
 Papillary (areolar)
 Reticular (dense irregular)
 Hypodermis (subcutaneous)

 Areolar and adipose

connective tissue
 Anchors skin to
underlying structures
 Allows skin to slide
freely
 Larger in women than
men
Epidermal Appendages

 Glands
 Hair
 Nails
 Exocrine Glands Sebaceous

 Sebaceous (oil) glands

 Occur over entire body, except palms
and soles
 Produce sebum as lubricant Merocrine
 Sudoriferous (sweat) glands
 Merocrine glands – most
numerous, sweat or sensible
perspiration
 Apocrine glands – confined to Apocrine
axillary, nipple, anal and genital
areas; viscous sweat
Hair: Structure

 Hair is composed of dead epidermal cells that

begin to grow and divide in the base of the
hair follicle.
 As the cells are pushed toward the skin
surface, they become keratinized and die.
 Hair color is genetically determined.
Hair Growth and Replacement

 Scalp hair grows for 2 to 5 years.

 Approximately 50 hairs are lost each day.
 Sustained hair loss of more than 100 hairs
each day usually indicates that something is
wrong.
Hair Growth
 Rate of hair growth is
about 2 mm/week
 Growth cycles – active
(2-5 years) and dormant
phases (3-4 months)
Hair
Three types of hair:
 Lanugo
 Terminal
 Vellus
 Hair
 Consists of root and
shaft
 Layers of the hair:
 Medulla – central core
not found in all hair
 Cortex – surrounds
medulla
 Cuticle – outermost
layer
Location and Functions
 Hair can be found EVERYWHERE, except
for on the palms, soles, lips, sides of fingers
and toes, parts of the external genitalia,
nipples
 Functions:
 Protects from the sun and sweat
 Senses touch
 Reduces heat loss
 Screens nasal passages
Male Pattern Baldness
 Genetic and hormonal
influences
 Genetic: 2 alleles, one for
uniform hair growth and one
for baldness
 Baldness gene is dominant in
males
 Hormonal: Testosterone causes
terminal hair to be replaced by
vellus hair
Nails
 Scale like
modification of
epidermis
 Contain hard keratin
 Grows from the nail
matrix
Nails:

- Produced by cells in the epidermis

- Nail plate (body): visible portion
- Nail root: located under cuticle
- Lunula: half moon crescent shaped
white portion under cuticle
- Nail bed: located under nail plate
- Hypoxia: decr. oxygen in blood, nail bed will
turn blue- cyanosis
Integumentary System Functions
 Protection (chemical, physical, and
biological barriers)
 Prevents loss of water
 Temperature regulation
 Metabolic regulation
 Immune defense
 Sensory receptors
 Excretion by means of secretion
Physiology:
Protection
-Physical barrier that protects underlying
tissues from injury, UV light and bacterial
invasion.

Regulation of body temp.

- high temp. pores open sweat comes to surface
and is evaporated.
Sensation:
- nerve endings and receptors that detect
pain, touch, pressure and temp.
Pacinian corpuscles: pressure
Meissner’s corpuscle: light touch

Excretion:
- sweat removes water, salts, uric acid and
ammonia from body surface.

Synthesis of Vit. D (calciferol):

- UV light stimulates skin to make Vit. D.
Effects of Aging on the Skin
 Skin vascularity and the number of sweat and
sebaceous glands decrease, affecting
thermoregulation.
 Inflammatory response and pain perception
diminish.
 Thinning epidermis and prolonged wound healing
make elderly more prone to injury and skin
infections.
 Skin cancer more common.
Assessment of Skin
There are seven parameters that should be
examined in performing physical
assessment of the skin:

 Integrity.  Texture.
 Color.  Turgor and mobility.
 Temperature and  Sensation.
moisture.  Vascularity.
 Skin Lesions
Primary Lesions

1. Macule and Patch – Flat, nonpalpable skin color

change
Macule - <1cm, circumscribed border
Patch - >1cm, may have irregular border
2. Blisters – Circumscribed, elevated, palpable mass
containing serous fluid
Vesicle - <.5cm
Bullae - >.5cm
3. Papule and Plaque – Elevated, palpable, solid mass,
circumscribed border
Papule - <.5cm
Plaque - >.5cm, flattened lesion
4. Wheal – Elevated mass with transient borders,
often irregular, with surrounding edema
5. Nodule and tumor – Elevated, palpable solid mass,
extends deeper into the dermis than a papule
Nodule - .5 – 2cm circumscribed
Tumor - >1-2cm, don’t have always sharp borders
6. Pustule – Pus – filled blisters or papules
7. Cyst – Encapsulated fluid – filled or semisolid mass
in the subq tissue or dermis
Secondary Lesions
 Scale- flaky accumulation of excess keratin
 Crust- collection of inflammatory cells and
dried serum, blood or pus
 Erosion – loss of superficial epidermis
 Scar – skin mark left after healing of a
wound or lesion
 Fissure – crack in the epidermis usually
extending into the dermis
 Keloid – hypertrophied scar tissue, excessive
collagen formation
 Ulcer - deeper erosion, loss of epidermis and
papillary dermis
 Lichenification-thickening of skin secondary to
chronic rubbing, irritation and scratching
Vesicular Lesions
 Petechia – small, 1-2mm round red or purple macule
 Ecchymosis – round or irregular macular lesion, larger
than petechia
 Cherry angioma – papular and round, normal age –
related skin alteration
 Spider angioma – red arteriole lesion, central body with
radiating branches, noted of face, neck arms and trunk
 Telangiectasia – spider-like or linear, bluish or red, noted
on legs and anterior chest, secondary to superficial dilation
of venous vessels and capillaries
Primary Lesions
Secondary Lesions
Vesicular Lesions
Common Diagnostic Tests for
Integumentary Disorders
 Biopsy  Wood’s light
1. Shave examination
2. Punch  Culture and
3. Incision sensitivity.
4. Excision
 Patch Testing.
 Tzanck smear.
 Skin scrapings.
Diagnostic Tests

1) Skin Biopsy
 Punch, excisional, incisional & shave

Nursing Interventions
Preprocedure - Secure consent
- clean site
 Postprocedure – place specimen in a clean
container & send to pathology laboratory
– use aseptic technique for
biopsy site dressing, assess site for bleeding
& infection
– instruct px to keep dressing in
place for 8hrs & clean site daily
Diagnostic Tests

2) Skin Culture
 Used for microbial study

 Viral culture is immediately placed on ice

3) Wood’s Light Examination
 Skin is viewed through a Wood’s glass under
UV

Nursing Interventions
Preprocedure – darken room
Postprocedure – assist px in adjusting to light
Diagnostic Test

4) Skin Testing
 Administration of an allergen by patch
or ID techniques

Nursing Interventions
Preprocedure – d/c systemic steroids or
antihistamines 48º prior, consent,
ready resuscitation equipments
Postprocedure
– keep skin-patch area dry
– instruct to avoid activities which can
increase sweating if doing a patch test
– record site, date, time of test, ff-up &
reading
Wounds

 A disruption in the integrity of the body.

 Three phases of healing:
 Defensive (inflammatory) phase.

 Reconstructive (proliferative) phase.

 Maturation phase.
Wound Drainage: Types

 Serous Exudate (composed primarily of

serum, the clear portion of blood; watery in
appearance).
 Purulent exudate (also called pus; may vary
in color).
 Hemorrhagic exudate (has a large
component of RBCs; color depends on
whether bleeding is old or fresh),
Factors Affecting Wound Healing

 Age.
 Oxygenation.
 Smoking
 Drug therapy.
 Diseases such as diabetes.
 Nutrition and diet.
Wound Care
 3 types of wound dressings:
1. Passive
2. Interactive
3. Active
5 Rules of Wound Care
1. Categorization
2. Selection
3. Change
4. Evolution
5. Practice
Categories of Dressings

1. Occlusive
2. Wet
3. Moisture – retentive
a. Hydrogels
b. Hydrocolloids
c. Foam dressings
d. Calcium Alginates
INTEGUMENTARY

DISORDERS
Pruritus

 Itch-scratch cycle

Interventions:
- Antihistamines
- Avoid hot environment
Hydradenitis Suppurativa

 Chronic suppurative folliculitis of perianal,

axillary and genital area or under breast
 Commonly after puberty
 Unknown cause but genetics
 Abnormal blockage of sweat glands causes
recurrent inflammation then scarring occurs
Management

 Hot compresses
 Antibiotics
 Isotretinoin
 I and D
 Surgery
Seborrheic Dermatoses
 Chronic increase production of sebum
 Etiology:
 Genetic
 Hormones
 Nutritional status
 Infection
 Emotional stress
 2 forms
 Oily
 Dry
Management

 No cure for seborrhea

 Corticorsteriods
 Maximal aeration of skin folds
 Frequent shampooing
 Antiseborrheic shampoo
Acne Vulgaris

 Inflammation of sebaceous glands and hair

follicles
 Etiology
 Unknown but related to:
 Heredity
 Cosmetic use
 Drugs
 Bacteria
Assessment

 Papule
 Pustule
 Nodule
 Comedones
Acne Vulgaris

Management:
 Topical

- Benzoyl peroxide
- Retinol
 Systemic

- Tetracycline
- Clindamycin
Eczematous Disorders
Atopic Dermatitis
Atopic Dermatitis
Etiology    
 Unknown

 occurs more frequently in children

 When one or both parents have allergies like asthma, hay

fever, or contact dermatitis

 Infantile eczema - infant allergies

 Eczema in older children - allergies to dust mites

 Intensified by dry skin, detergents, constricting clothing, or

perfumed soaps and lotions
Atopic Dermatitis
S/S:     
 Infancy: red papules (raised lesions) usually appears
first in the cheeks and then spread to the forehead,
scalp, and down extensor surfaces of the arms and legs
 Intense Pruritus

 Childhood eczema characterized by dry, scaly, papular

patches of skin on wrists, hands, ankles, antecubital and
popliteal spaces
 No laboratory diagnostic test for eczema
Nursing Interventions
 Bathe or shower daily with tepid water using mild
soap only on nonaffected areas
 Pat, rather than rub, skin dry
 Immediately after bath, apply emollient such as
Eucerin or Lubriderm
 Avoid use of scented or perfumed lotions
 Apply wet wraps to severely affected skin after
applying topical medications
 Use antibacterial soaps for hand washing
 Avoid wool or constricting clothing which can trap
perspiration
Nursing Interventions
Administer prescribed meds as ordered
1.  Topical steroids (hydrocortisone 1% or
triamcinolone 0.1%) are applied to lesions
to reduce inflammation during flare ups
2. Antihistamines to control itching
3. Oral antibiotics for secondary infections
Nursing Interventions

Perform health teaching on:

1. Identify foods that

exacerbate rash
2. Avoid suspected
environmental allergens
Contact Dermatitis
 Skin reacts to external irritants like:
 allergens (e.g. poison ivy or cosmetics).

 harsh chemical substances (detergents,

insecticides).
 metals such as nickel.

 mechanical irritations from wool or glass

fibers.
 body substances like urine or feces.
Contact Dermatitis

Assessment:
a. Pruritus
b. Burning
c. Edema
d. Erythema
e. Vesicles with drainage
Contact Dermatitis

 Treatment:
1. Antihistamines
2. Prophylactic antibiotics
3. Topical steroids
Interventions:
a. Elevate to reduce edema
b. Cold compress
c. Prevent scratching
d. Assist in skin testing
e. Use hypoallergenic materials
f. Administer antibiotics, antipruritics,
steroids
Exfoliative Dermatitis
 Progressive inflammation of the skin gradually
worsens.
 The entire body is affected. Chills, fever, and
malaise set in.
 Severe reactions to drugs such as penicillin
may be causative. May also be due to
underlying skin or systemic disease
 Exfoliative dermatitis can be fatal.
Manifestations
 Generalized erythema
 Fever and GI symptoms
 Skin color turning dark red
 Scaling after a week
 High output heart failure
 Hyperuricemia
Management

 Comfortable room temperature

 Fluid and Electrolyte balance
 Antibiotics
 Oral/Parenteral Steroids
 Provide symptomatic relief
Scaling Disorders
Psoriasis

 A chronic inflammatory disease marked by epidermal

proliferation
 High incidence among Caucasian/European
 Most common in 15 – 35 yrs old

 Etiology:
 Unknown but related to heredity/genetics

 Exacerbating factors:

Local trauma, Overexposure to sun, Infection and Illness

Psoriasis
 Manifestations
 Profuse, erythematous silvery scales or
plaques.
 Often covering large areas of the body
 Pruritus, accompanied with pain
 Psoriatic arthritis
 Guttate psoriasis
 Palmar – pustular psoriasis
 Erythrodermic psoriasis
Psoriasis
Psoriasis
Psoriasis
Nursing Management
 Gentle removal of scales
 Coal tar therapy/Oil baths

 Topical corticosteroid

 Discuss the administration of additional medical treatments

 Topical nonsteroidal – Calcipotreine and Tazarotene

 Intralesional therapy

 Systemic cytotoxic medication

1. Methotrexate
2. Hydroxyurea
3. Cyclosporine
4. Oral retinoids
 Photochemotherapy
Nursing Management
 Photochemotherapy
 Binds with DNA and decrease cell proliferation
 Oral psoralens, phototherapy of UV A light (PUVA) or
(PUVB)
Pyodermas
Impetigo
Impetigo
 A highly contagious, superficial skin infection
caused by staphylococci or streptococci or both
Impetigo
Etiology: 
 Acquired through contact with infected
person who share toys, books, towels, or
toiletries
 GABH Streptococci

 Bullous impetigo always caused by S.

aureus
Impetigo
Manifestations
 Painful, burning sensation over lesions

 Pruritus may be present

 Nonbullous impetigo begins as a single

erythematous macule that rapidly progresses to a

vesicle or pustule.
 Pustule ruptures leaving a honey-colored crust

over the superficial erosion

 Mild regional lymphadenopathy may occur
Nursing Management
 Soak crusts in warm water
 Gently wash with antibacterial soap
and remove crusts
 Good hand washing
 Do not touch or pick at lesions
 Keep fingernails short and clean to
prevent spread of infection
Nursing Management
 Administer meds as ordered
 Topical antibiotic

 Systemic antibiotic for:

1. Non bullous – Oral penicillin

2. Bullous – Cloxacillin, Dicloxacillin

3. Penicillin allergy - Erthyromycin

Erysipelas & Cellulitis
Erysipelas
– inflammation, acute, superficial, rapidly spreading
caused by B-hemolytic Streptococcus

Cellulitis
– inflammation/infection of deeper dermis usually
caused by Streptococcus pyogenes
Erysipelas & Cellulitis

 Assessment:
- Swelling or edema
- Redness
- Pain or tenderness
- Fever
- Pruritus
Erysipelas & Cellulitis

 Treatment:
- IV antibiotics (Penicillin, Cloxacillin)
- Antipyretics
- Elevate affected area
- Warm compress for 2x a day
Folliculitis, Furuncle, Carbuncle
 Folliculitis
 - infection of hair follicle
 Furuncle
 - deep in 1 or more hair follicles and spread in
surrounding dermis
 Carbuncle
 - abscess of the skin and subcutaneous tissues;
extension of a furuncle, large and deep - seated
Folliculitis, Furuncle, Carbuncle
 Assessment:
- Papule, pustule, nodule, node, cyst
- Fever
- Pain and tenderness
Folliculitis, Furuncle, Carbuncle
Management
- Don’t destroy wall of induration

- Never squeeze or prick, specially if in the face

- Oral antibiotics

- Bed rest

- I and D

- Warm, moist compress

- Wear gloves
Fungal Infections
Tinea

Etiology:
- Dermatophytes, yeasts

1. Tinea Pedis
- Prevalent on communal showers and pools
- Potassium permanganate
- Topical antifungal agents
- Keep feet dry as possible
Tinea
2. Tinea Corporis
- ringed lesions on face, neck, trunk and extremities
- animal contact (pets)
- topical antifungal
- use clean towel daily
3. Tinea Capitis
- hair shafts
- red scaling patches
- classic sign: “black dots”, temporary hair loss
- Griseofulvin; topical has no effect
- shampoo 2-3x a week with Nizoral
Tinea
4. Tinea Cruris
- “itch jock”
- young, joggers, obese and tight clothing
- topical antifungal
- avoid excessive heat
- avoid synthetic clothing and wet bathing suit
5. Tinea Ungum
- onychomycosis
- nails become thickened and friable and lusterless
- antifungal therapy 6 weeks for fingernails and 12
weeks for toenails
Candidal Intertrigo

Predisposing factors:
 Obesity

 DM

 Recent antibiotic therapy

 Warm, moist environment

Candidal Intertrigo

Hx and Assessment:
 Pruritus

 Pain

 Well-demarcated, beefy-red, erythematous

patches surrounded by satellite pustules

 Restricted to intertriginous areas

 In infants- diaper rash

Candidal Intertrigo

Treatment:
 Topical antifungal

 Reduce moisture

 Reduce friction through weight loss

Parasitic Infections
Pediculosis Capitis

 Infestation of the hair and scalp with

lice
 Highly communicable parasite
 Spread through direct or indirect
contact
Pediculosis Capitis
Etiology: 
 Lice live and reproduce only in humans

 Incubation period 8 to 10 days

 Lice can survive for up to 48 hours from human

host
 Nits can survive for 8 to 10 days away from human
host
 Lice bites release saliva into dermis which causes
itching
Pediculosis Capitis
Manifestations
 Look for nits – silvery, glistening oval bodies

 Commonly found in back of neck and ears

 Pruritus

 Erythema, scaling, and skin excoriation

Nursing Management
 Apply about 2 oz of pediculicide; agent onto wet hair
and add additional water to lather
 Rinse hair thoroughly
 Remove nits from damp hair
 Delouse environment by washing all of child’s daily
clothes and linens in hot water and detergent and
drying fro 20 minutes in a hot dryer
 Stuffed toys and items that cannot be washed should be
sealed in a plastic bag for 2 weeks to make sure nits are
dead
Nursing Management
 Administer meds as ordered:
 Permethrin (Nix), Pyrethrum
(Rid), Lindane (Kwell)
 After initial treatment, one
additional treatment may be
needed no sooner than 7 days
Scabies
 Contagious skin condition caused by the
human mite sarcoptes scabiei
 May affect anyone
Scabies
Assessment:
 Lesions appear as linear, grayish burrows
1 to 10 cm long ending in a pinpoint
vesicle, papule, or nodule
 Lesions - @ webs of the fingers, body
creases, axilla, waistline, and near
genitalia
 Secondary lesions (crust, vesicles, nodules
& excoriations)
 Intense pruritus that worsens at night
Scabies

 Diagnosis
 Scraped skin from the burrows placed on a slide
and examined through a microscope
Nursing Management
 Warm soap and water bath
 Apply scabidal lotion to cool, dry skin over the entire
body
 Leave on for 12 to 24 hours before washing off
 Treat all contacts
 Clothing, bedding, and towels should be changed daily
 Vacuum floors, carpets, and furniture
 Items that cannot be washed should be bagged for 4
days before use
Nursing Management
 Administer meds as ordered:
1. Crotamiton (Eurax), Permethrin 5%
cream (Elimite), and Lindane (Kwell,
Scavene).
2. Oral antihistamines
3. Soothing creams or lotions
4. Antibiotics for secondary infection if
present
Autoimmune disorders
Pemphigus

 Group of serious skin disease characterized by

appearance of bullae on normal skin and
mucous membranes
 Genetics, Jewish or Mediterranean
 Middle and late adulthood
 Also associated with the use of penicillins,
captopril and myasthenia gravis
Pemphigus
 Clinical manifestations
 Oral lesions – painful, bleed easily and heal slowly
 Skin bullae rupture and leave painful eroded areas
that are oozing and weeping
 Offensive odor
 Nikolsky’s sign
 Complications:
 Secondary bacterial infections
 Fluid and electrolyte imbalances
 Hypoalbuminemia
Pemphigus

 Nursing management
 Corticosteroids in High doses
 Immunosuppresants
 Plasmapheresis
TEN and Stevens Johnson Syndrome
 a life-threatening condition affecting the skin,
in which due to cell death the epidermis
separates from the dermis.
 Etiology:
 hypersensitivity complex affecting the skin

and the mucous membranes

 idiopathic

 possible medications

 infections
TEN and Stevens Johnson Syndrome
 Infections
 herpes simplex virus, influenza, mumps,

histoplasmosis, Epstein-Barr virus

 Allergic reactions to drugs
 (Dicloflex, Fluconazole, Valdecoxib, Penicillins,

Barbiturates, Sulfas, Phenytoin, Modafinil, Ibuprofen

 Idiopathic factors (up to 50% of the time)
 Malignancy (carcinomas and lymphomas)
 Herbal supplements containing ginseng. SJS may also
be caused by cocaine usage
TEN and Stevens Johnson Syndrome
 Clinical manifestations
 Skin cracks

 Blisters on the lips and mouth

 Fever and red patches on the skin

 Burning sensation of the skin with extensive blistering

and ulceration
 May be localized to one part of the body or systemic

from head to toe

 Mucosal involvement

 Scalded – skin syndrome

TEN and Stevens Johnson Syndrome
TEN and Stevens Johnson Syndrome
TEN and Stevens Johnson Syndrome
 Steroids like prednisone
 Antipyretics

 Analgesics

 Offending drug must be removed at

once!
 IV Ig
Nursing Management
 Administer meds as ordered
 Assess for s/s of infection
 Maintain hydration status of the pt
 Apply petroleum jelly over the skin lesions to
prevent excessive dryness
 WOF s/s of bleeding/ hypotension/ shock
 Prepare to administer Potassium
Permanganate
Nursing Management
 Potassium per Manganate
 Dilute in 1 L of sterile water
 Enough to make it light pink to prevent
burns
 Let it drip over open lesions to promote
healing and dryness
 Psychosocial support
Burn Injury
 an alteration in skin integrity
resulting in tissue loss or injury
caused by heat, chemicals,
electricity or radiation.
Burn Injury
Causes:
 Thermal

 results from dry heat (flames) or moist

heat(steam or hot liquids). It is the most

common type.
 Chemical

 caused by direct contact with either acidic or

basic agents. It destroys tissue perfusion

leading to necrosis
Burn Injury
 Electrical
 severity depends on type and duration of current and

amount of voltage.
 It follows the path of least resistance (muscles, bone, blood

vessels and nerves).

 Includes direct current, alternating current and lightning.

 Radiation
 usually associated with sunburn or radiation treatment for

cancer. It is usually superficial. Extensive exposure to

radiation may lead to tissue damage and multisystem
damage.
Classification of burn according to depth:
Superficial/partial Deep partial thickness Full thickness burn (3rd
thickness burn (1st burn degree)
degree)

Area involved epidermis Epidermis and part of dermis Epidermis, dermis

hypodermis.

Appearance

Clinical findings Very painful, tingling and Severe pain, sensitivity to cold Painless, dry, pale white or
hyperesthesia, erythema, air, blistering, edema charred, shock, hematuria
blanching, minimal or no and hemolysis.
edema.

Causes Sunburn, flash of flame Scalding, prolonged contact Fire, prolonged exposure

Treatment cooling Grafting Grafting scarring,

escharotomy
Classification of burns based on extent
1. Minor Burn Injury
- 2nd degree burn of <15% total body surface area (TBSA) in adults or <10%
TBSA in children
- 3rd degree burn of <2% TBSA not involving special care areas
- Excludes all patients with electrical injury, inhalation injury or concurrent
trauma and all poor-risk patients

2. Moderate, Uncomplicated Burn Injury

- 2nd degree burns of 15-25% TBSA in adults or 10-20% in children
- 3rd degree burns of <10% TBSA not involving special care areas
- Excludes all patients with electrical injury, inhalation injury or concurrent
trauma and all poor-risk patients

3. Major Burn Injury

- 2nd degree burns >25% TBSA in adults or >20% in children
- All 3rd degree burns >10% TBSA
- All burns involving special care areas
- All Inhalation injury, electrical injury or concurrent trauma and poor risk
patients
Burn Injury
Assessment
 Extent of burn using body surface area and cause.

 Head and both upper ext., 9% each; front and back of trunk, 18%
each, lower ext., 18%; perineum 1%
 Cardiac status/BP, dehydration and shock

 Respiratory status-airway patency

 Pain management requirements

 Increased nutritional needs

 Mobility deficits

 Past medical history which may require more intense

observation (e.g DM, CVD, etc)
Physiologic Changes Following Burns
Hypovolemic phase Changes Diuretic phase

-vascular to interstitial Extracellular fluid shift -interstitial

to vascular
hemoconcentration hemodilution
- renal flow from BP & C.O. Renal function - renal flow from blood v.
oliguria diuresis
-Na reabsorption by kidneys but Na level -Naloss with diuresis, becomes
Na lost in exudate and trapped normal in 1 week.
in edema fluid.
Na deficit Na deficit

-released by tissue and RBC K level -Kmoves back into cells, lost
injury, decreased excretion by diuresis.
from decreased renal function.
hyperkalemia hypokalemia
Loss into tissues through CHON level -lossduring continued
increased capillary permeability catabolism

hypoproteinemia hypoproteinemia

-Tissue catabolism; CHON loss Nitrogen balance -tissue

catabolism, CHON loss
in tissue; more nitrogen loss immobility
that take in
negative nitrogen negative nitrogen
balance balance

-Anaerobic metabolism from Acid-base balance

decreased tissue perfusion;
increased acid and products
decreased renal output (this
leads to retention of acids end
products) loss of NaHCO3

metabolic acidosis

-occurs because of trauma Stress response Occurs because of prolonged

nature of injury or psychological
decreased renal flow threat to self
stress ulcers
Burn Injury
Diagnostic and lab test findings
 CBC-elevated HCT and decrease HGB due to fluid

shifts.
 UO indicated adequacy of renal status

 Electrolytes-decrease sodium and increase potassium

due to fluid shift

 BUN and creatinine-elevated due to dehydration

 ABG’s and pulse oximetry-assess respiratory failure.

 CVP - hydration status

Burn Injury
Goal of care
 Maintain fluid balance

 Prevent and manage infection

 Preserve mobility

 Decrease pain
Phases of Burn Management

1. Emergent/ Shock Phase

2. Acute/ Diuretic Phase
3. Rehabilitative Phase
Emergent/Resuscitative/ Shock Stage
 Lasts from the onset of injury through
successful fluid resuscitation
 Fluid shifting from IVC - ITC
Emergent/Resuscitative/Shock Stage

Diagnostic and lab test findings-

 Elevated hematocrit and decreased

hemoglobin due to fluid shift

 *Decreased sodium and increased

potassium due to fluid shift

 Elevated BUN and creatinine due to

dehydration
Emergent/Resuscitative/Shock Stage
 Fluid resuscitation
Consensus formula
 2-4mL/kg/%TBSA burn
 ½ given first 8 hrs.
 ½ next 16

Parkland (Baxter)
 4 ml/kg/%BSA burn for 24 hour pd.
 ½ first 8 hrs
 ½ next 16 hrs
Nursing Interventions
 remove jewelry and clothing to decrease
constriction of affected area,
 flush burn with water,

 evaluate extent and depth of burn,

 cover burn with clean cloth,

 arrange transfer to emergency

facility
 maintain airway clearance.
Nursing Interventions
 Medication Therapy
 Pain therapy
 Tetanus prophylaxis
 Topical antimicrobial as well as systemic
antibiotics
Emergent/Resuscitative Stage

High Priority Nursing Diagnoses

 Fluid volume deficit

 Ineffective airway
 Altered nutrition requirements
Acute/ Diuretic Stage
 Begins with the start of diuresis and
ends with closure of the burn wound
 Movement of fluid from ITC-IVT

 S/s of hypervolemia, CHF

 Needs proper regulation of fluid intake

Nursing Interventions
 Wound care management

 Nutritional therapies

 Infection control

 Pain management

 Psychosocial support

 Physical therapy

 Hydrotherapy

 Maintain fluid/hydration status

 Maintain heated environment.

Nursing interventions
 Medication Therapy
 Antibiotic therapy-topical and

systemic
 Narcotic pain control usually

required
 IV fluid administration
Autografting
care of graft site
a. Elevate & immobilize
b. Keep free from pressure
c. Check for infection
d. Instruct client to protect affected
area from sunlight
e. Use splints & support garment
Rehabilitative Stage
 Begins with wound closure and ends
when the client returns to the highest
level of health restoration.
Nursing Interventions
 Psychosocial evaluation,
 Support and management-arrange
counseling if necessary,
 Prevention of immobility
contractures-exercises or ongoing
physical therapy
 Assist in resumption to work,
family and social life.
 Preventative measures for scar
formation
 Assess home environment for
needs and accessibility