1. Description

a. Skin biopsy is the collection of a small piece of skin tissue for histopathological study.

b. Methods include punch, excisional, and shave.

2. Preprocedure interventions

a. Verify informed consent has been obtained.

b. Cleanse site as prescribed.

3. Postprocedure interventions

a. Place specimen in the appropriate container and send to pathology laboratory for analysis.

b. Use surgically aseptic technique for biopsy site dressings.

c. Assess the biopsy site for bleeding and infection.

d. Instruct the client to keep dressing in place for at least 8 hours, and then clean daily and use

antibiotic ointment as prescribed (sutures are usually removed in 7 to 10 days).

e. Instruct the client to report signs of excessive drainage or redness or other signs of infection.

B. Skin/wound cultures

1. A small skin culture sample is obtained with a sterile applicator and the appropriate type of

culture tube (e.g., bacterial or viral). Methods include scraping, punch biopsy, and collecting

fluid.

2. Postprocedure intervention

a. Viral culture is placed immediately on ice.

b. Sample is sent to laboratory to identify an existing organism.

Obtain skin culture samples or any other type of culture specimens before instituting

antibiotic therapy.

C. Wood’s light examination

1. Description: Skin is viewed under ultraviolet light through a special glass (Wood’s glass) to

identify superficial infections of the skin.

2. Preprocedure intervention: Darken the room before the examination.

3. Postprocedure intervention: Assist the client during adjustment from the darkened room.

D. Diascopy

1. Technique allows clearer inspection of lesions by eliminating the erythema caused by increased

blood flow to the area.

2. A glass slide is pressed over the lesion, causing blanching and revealing the lesion more

clearly. 

A. Description

1. A superficial fungal infection of the skin and mucous membranes

2. Also known as a yeast infection, or thrush when it occurs in the mouth

3. Risk factors include immunosuppression, such as in clients with acquired immunodeficiency

syndrome; cancer clients receiving chemotherapy; clients undergoing long-term antibiotic

therapy; clients with diabetes mellitus; and obese clients.

4. Common areas of occurrence include the mucous membranes of the mouth, perineum, vagina,

axilla, and under the breasts.

B. Assessment

1. Skin: Red and irritated appearance that itches and stings

2. Mucous membranes of the mouth: Red and whitish patches

C. Interventions

1. Teach the client to keep skin fold areas clean and dry.

2. For the hospitalized client, inspect skin fold areas frequently, turn and reposition the client

frequently, and keep the skin and bed linens clean and dry.

3. Provide frequent mouth care as prescribed and avoid irritating products.

4. Provide food and fluids that are tepid in temperature and nonirritating to mucous membranes.

5. Antifungal medications may be prescribed.

A. Description

1. With a history of chickenpox, shingles is caused by reactivation of the varicella-zoster virus;

shingles can occur during any immunocompromised state in a client with a history of

chickenpox.

2. The dormant virus is located in the dorsal nerve root ganglia of the sensory cranial and spinal

nerves.

3. Herpes zoster eruptions occur in a segmental distribution on the skin area along the infected

nerve and show up after several days of discomfort in the area.

4. Diagnosis is determined by visual examination, and by Tzanck smear and viral culture that

identify the organism.

5. Postherpetic neuralgia (severe pain) can remain after the lesions resolve.

6. Herpes zoster is contagious to individuals who never had chickenpox and who have not been

vaccinated against the disease.

7. Herpes simplex virus is another type of virus; type 1 infection causes a cold sore (usually on the

lip) and type 2 causes genital herpes (both types are contagious).

B. Assessment

1. Unilaterally clustered skin vesicles along peripheral sensory nerves on the trunk, thorax, or face

2. Fever, malaise

3. Burning and pain

4. Paresthesia

5. Pruritus

C. Interventions

1. Isolate the client because exudate from the lesions contains the virus (maintain standard and

other precautions as appropriate, such as contact precautions).

2. Assess for signs and symptoms of infection, including skin infections and eye infections; skin

necrosis can also occur.

3. Assess neurovascular status and seventh cranial nerve function; Bell’s palsy is a complication.

4. Use an air mattress and bed cradle on the client’s bed if hospitalized, and keep the environment

cool; warmth and touch aggravate the pain.

5. Prevent the client from scratching and rubbing the affected area.

6. Instruct the client to wear lightweight, loose cotton clothing and to avoid wool and synthetic

clothing.

7. Teach the client about the prescribed therapies; astringent compresses may be prescribed to

relieve irritation and pain and to promote crust formation and healing.

8. Teach the client about measures to keep the skin clean to prevent infection.

9. Teach the client about topical treatment or antiviral medications if prescribed.

10. Zostavax, the vaccination for shingles, is recommended for adults 60 years of age and older to

reduce the risk of occurrence and the associated long-term pain.

11. Antiviral medications may be prescribed; refer to Chapter 71 for information on antiviral

medications.

A. Description

1. Skin or wound becomes infected with methicillin-resistant Staphylococcus aureus (MRSA).

2. MRSA is also referred to as a health care-associated infection. See Chapter 16 for additional

types of health care-associated infections.

3. Infection can range from mild to severe and can present as folliculitis or furuncles.

4. Folliculitis is a superficial infection of the follicle caused by Staphylococcus and presents as a

raised red rash and pustules; furuncles are also caused by Staphylococcus and occur deep in

the follicle, presenting as very painful large raised bumps that may or may not have a pustule.

5. If MRSA infects the blood, sepsis, organ damage, and death can occur.

MRSA is contagious and is spread to others by direct contact with infected skin or

infected articles; for the client with MRSA, the infection can also be spread to other parts of

the body.

B. Assessment: A culture and sensitivity test of the skin or wound confirms the presence of MRSA

and leads to choice of appropriate antibiotic therapy.

C. Interventions

1. Maintain standard precautions and contact precautions as appropriate to prevent spread of

infection to others.

2. Monitor the client closely for signs of further infection, which may result in systemic illness or

organ damage.

3. Administer antibiotic therapy as prescribed.

A. Description

1. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics

caused by group A Streptococcus, which enters the tissue via an abrasion, bite, trauma, or

wound.

2. Cellulitis is an infection of the dermis and underlying hypodermis; the causative organism is

usually group A Streptococcus or Staphylococcus aureus.

B. Assessment

1. Pain and tenderness

2. Erythema and warmth

3. Edema

4. Fever

C. Interventions

1. Promote rest of the affected area.

2. Apply warm compresses as prescribed to promote circulation and to decrease discomfort,

erythema, and edema.

3. Apply antibacterial dressings, ointments, or gels as prescribed.

4. Administer antibiotics as prescribed for an infection; obtain a culture of the area before

initiating the antibiotics.

A. Description: A dermatitis that develops from contact with urushiol from poison ivy, oak, or sumac

plants

B. Assessment

1. Papulovesicular lesions

2. Severe pruritus

C. Interventions

1. Cleanse the skin of the plant oils immediately.

2. Apply cool, wet compresses to relieve the itching.

3. Apply topical products to relieve the itching and discomfort.

4. Topical or oral glucocorticoids may be prescribed for severe reactions.

A. Spider bites

1. Almost all types of spider bites are venomous and most are not harmful, but bites or stings from

brown recluse spiders, black widow spiders, and tarantulas (and from scorpions, bees, and

wasps as well) can produce toxic reactions in humans.

2. Brown recluse spider

a. Bite can cause a skin lesion, a necrotic wound, or systemic effects from the toxin

(loxoscelism).

b. Application of ice to decrease enzyme activity of the venom and limit tissue necrosis should

be done immediately and intermittently for up to 4 days after the bite.

c. Topical antiseptics and antibiotics may be necessary if the site becomes infected.

3. Black widow spider

a. Bite causes a small red papule.

b. Venom causes neurotoxicity.

c. Ice is applied immediately to inhibit the action of the neurotoxin.

d. Systemic toxicity can occur and the victim may require supportive therapy in the hospital.

4. Tarantulas

a. Bite causes swelling, redness, numbness, lymph inflammation, and pain at the bite site.

b. The tarantula launches its barbed hairs, which penetrate the skin and eyes of the victim,

producing a severe inflammatory reaction.

c. Tarantula hairs are removed as soon as possible, using sticky tape to pull hairs from the skin,

and the skin is thoroughly irrigated; saline irrigations are done for eye exposure.

d. The involved extremity is elevated and immobilized to reduce pain and swelling.

e. Antihistamines and topical or systemic corticosteroids may be prescribed; tetanus

prophylaxis is necessary.

B. Scorpion stings

1. Scorpions inject venom into the victim through a stinging apparatus on their tail.

2. Most stings cause local pain, inflammation, and mild systemic reactions that are treated with

analgesics, wound care, and supportive treatment.

3. The bark scorpion can inflict a severe and fatal systemic response; the venom is neurotoxic; the

victim should be taken to the emergency department immediately (an antivenom is administered

for bark scorpion bites).

C. Bees and wasps

1. Stings usually cause a wheal and flare reaction.

2. Emergency care involves quick removal of the stinger and application of an ice pack.

3. The stinger is removed by gently scraping or brushing it off with the edge of a needle or similar

object; tweezers are not used because there is a risk of pinching the venom sac.

4. If the victim is allergic to the venom of a bee or wasp, a severe allergic response can occur

(hives, pruritus, swelling of the lips and tongue) that can progress to life-threatening

anaphylaxis; immediate emergency care is required.

5. Individuals who are allergic should carry an EpiPen (epinephrine autoinjector) for selfadministration

of intramuscular epinephrine if a bee or wasp sting occurs.

D. Snake bites

1. Some snakes are venomous and can cause a serious systemic reaction in the victim.

2. The victim should be immediately moved to a safe area away from the snake and should rest to

decrease venom circulation; the extremity is immobilized and kept below the level of the heart.

3. Constricting clothing and jewelry are removed before swelling occurs.

4. The victim is kept warm and is not allowed to consume caffeinated or alcoholic beverages,

which may speed absorption of the venom.

5. If transport to the emergency department is not done immediately, a constricting band may be

applied proximal to the wound to slow the venom circulation; monitor the circulation

frequently and loosen the band if edema occurs.

6. The wound is not incised or sucked to remove the venom; ice is not applied to the wound.

7. Emergency care in a hospital is required as soon as possible; an antivenom may be

administered along with supportive care.

For spider bites, scorpion bites, or other stings or bites, the Poison Control Center should

be contacted as soon as possible to determine the best initial management.

A. Description

1. Frostbite is damage to tissues and blood vessels as a result of prolonged exposure to cold.

2. Fingers, toes, face, nose, and ears often are affected.

B. Assessment

1. First-degree: Involves white plaque surrounded by a ring of hyperemia and edema

2. Second-degree: Large, clear fluid–filled blisters with partial-thickness skin necrosis

3. Third-degree: Involves the formation of small hemorrhagic blisters, usually followed by eschar

formation involving the hypodermis requiring debridement.

4. Fourth-degree: No blisters or edema noted; full-thickness necrosis with visible tissue loss

extending into muscle and bone, which may result in gangrene. Amputation may be required.

C. Interventions

1. Rewarm the affected part rapidly and continuously with a warm water bath or towels at 104° F

to 107.6° F (40° C to 42° C) to thaw the frozen part.

2. Handle the affected area gently and immobilize.

3. Avoid using dry heat, and never rub or massage the part, which may result in further tissue

damage.

4. The rewarming process may be painful; analgesics may be necessary.

5. Avoid compression of the injured tissues and apply only loose and nonadherent sterile

dressings.

6. Monitor for signs of compartment syndrome.

7. Tetanus prophylaxis is necessary, and topical and systemic antibiotics may be prescribed.

8. Debridement of necrotic tissue may be necessary; amputation may be necessary if gangrene

develops.

A. Actinic keratoses are caused by chronic exposure to the sun and appear as rough, scaly, red, or

brown lesions that are usually found on the face, scalp, arms, and backs of the hands.

B. Lesions can progress to squamous cell carcinoma.

C. Treatment includes medications, excision, cryotherapy, curettage, and laser therapy.

■ Aminolevulinic acid (Levulan Kerastick)

■ Diclofenac sodium 3% gel (Solaraze)

■ Fluorouracil (Carac, Efudex, Fluoroplex)

■ Imiquimod 5% cream (Aldara)

A. Description

1. Skin cancer is a malignant lesion of the skin, which may or may not metastasize.

2. Overexposure to the sun is a primary cause; other causes and conditions that place the

individual at risk include chronic skin damage from repeated injury and irritation, genetic

predisposition, ionizing radiation, light-skinned race, age older than 60 years, an outdoor

occupation, and exposure to chemical carcinogens.

3. Diagnosis is confirmed by skin biopsy.

B. Types

1. Basal cell: Basal cell cancer arises from the basal cells contained in the epidermis; metastasis

is rare but underlying tissue destruction can progress to organ tissue.

2. Squamous cell: Squamous cell cancer is a tumor of the epidermal keratinocytes and can

infiltrate surrounding structures and metastasize to lymph nodes.

3. Melanoma: Melanoma may occur any place on the body, especially where birthmarks or new

moles are apparent; it is highly metastatic to the brain, lungs, bone, and liver, with survival

depending on early diagnosis and treatment.

C. Assessment

1. Change in color, size, or shape of preexisting lesion

2. Pruritus

3. Local soreness

The client needs to be informed about the risks associated with overexposure to the sun

and taught about the importance of performing monthly self-skin assessments.

D. Interventions

1. Instruct the client regarding the risk factors and preventive measures.

2. Instruct the client to perform monthly self-skin assessments and to monitor for lesions that do

not heal or that change characteristics.

3. Advise the client to have moles or lesions removed that are subject to chronic irritation.

4. Advise the client to avoid contact with chemical irritants.

5. Instruct the client to wear layered clothing and use sunscreen lotions with an appropriate skin

protection factor when outdoors.

6. Instruct the client to avoid sun exposure between 10 AM and 4 PM.

7. Management may include surgical or nonsurgical interventions; if medication is prescribed

provide instructions about its use.

8. Assist with surgical management, which may include cryosurgery, curettage and

electrodessication, or surgical excision of the lesion.

A. Description

1. Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in

psoriatic patches; however, a break in skin integrity can lead to an infection in the affected

area.

2. Various forms exist, with psoriasis vulgaris being the most common.

3. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an

autoimmune reaction, and climate changes; a genetic predisposition may also be a cause.

4. The disorder may be exacerbated by the use of certain medications.

5. Koebner phenomenon is the development of psoriatic lesions at a site of injury, such as a

scratched or sunburned area.

6. In some individuals with psoriasis, arthritis develops that leads to joint changes similar to those

seen in rheumatoid arthritis.

7. The goal of therapy is to reduce cell proliferation and inflammation, and the type of therapy

prescribed depends on the extent of the disease and the client’s response to treatment.

B. Assessment

1. Pruritus

2. Shedding: Silvery, white scales on a raised, reddened, round plaque that usually affects the

scalp, knees, elbows, extensor surfaces of arms and legs, and sacral regions

3. Yellow discoloration, pitting, and thickening of the nails are noted if they are affected.

4. Joint inflammation with psoriatic arthritis

C. Pharmacological therapy: Refer to Chapter 51 for medications used to treat psoriasis.

D. Interventions and client education

1. Provide emotional support to the client with associated altered body image and decreased selfesteem.

2. Instruct the client in the use of prescribed therapies and to avoid over-the-counter medications.

3. Instruct the client not to scratch the affected areas and to keep the skin lubricated as prescribed

to minimize itching.

4. Monitor for and instruct the client to recognize the signs and symptoms of secondary skin

problems, such as infection, and to report these signs.

5. Instruct the client to wear light cotton clothing over affected areas.

6. Assist the client to identify ways to reduce stress if stress is a predisposing factor.

A. Description

1. Acne is a chronic skin disorder that usually begins in puberty and is more common in males;

lesions develop on the face, neck, chest, shoulders, and back.

2. Acne requires active treatment for control until it resolves.

3. The types of lesions include comedones (open and closed), pustules, papules, and nodules.

4. The exact cause is unknown but may include androgenic influence on sebaceous glands,

increased sebum production, and proliferation of Propionibacterium acnes (the enzymes

reduce lipids to irritating fatty acids).

5. Exacerbations coincide with the menstrual cycle in female clients because of hormonal activity;

oily skin and a genetic predisposition may be contributing factors.

B. Assessment

1. Closed comedones are whiteheads and noninflamed lesions that develop as follicles and

enlarge, with the retention of horny cells.

2. Open comedones are blackheads that result from continuing accumulation of horny cells and

sebum, which dilates the follicles.

3. Pustules and papules result as the inflammatory process progresses.

4. Nodules result from total disintegration of a comedone and subsequent collapse of the follicle.

5. Deep scarring can result from nodules.

C. Interventions

1. Instruct the client in prescribed skin-cleansing methods, with emphasis on not scrubbing the face

and using only prescribed topical agents.

2. Instruct the client in the administration of topical or oral medications as prescribed.

3. Instruct the client not to squeeze, prick, or pick at lesions.

4. Instruct the client to use products labeled noncomedogenic and cosmetics that are water-based,

and to avoid contact with products with an excessive oil base.

5. Instruct the client on the importance of follow-up treatment.

A. A drug-induced skin reaction that occurs through an immunological response

B. Similar to toxic epidermal necrolysis (TEN), another drug-induced skin reaction that results in

diffuse erythema and large blister formation on the skin and mucous membranes.

C. May be mild or severe, and may cause vesicles, erosions, and crusts on the skin; if severe,

systemic reactions occur that involve the respiratory system, renal system, and eyes, resulting in

blindness.

D. Most commonly occurs in clients with cancer who are receiving chemotherapy or immunotherapy

E. Treatment includes immediate discontinuation of the medication causing the syndrome; antibiotics,

corticosteroids, and supportive therapy may be necessary.

1. Assess for airway patency.

2. Administer oxygen as prescribed.

3. Obtain vital signs.

4. Initiate an intravenous (IV) line and begin fluid replacement as prescribed.

5. Elevate the extremities if no fractures are obvious.

6. Keep the client warm and place the client on NPO status.

The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent

hypovolemic shock, and preserve vital organ functioning. Therefore the priority action is to assess

for airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen.

The type of oxygen delivery system is prescribed by the health care provider. Oxygen is necessary

to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which

is needed for comparison of subsequent vital signs once fluid resuscitation is initiated. The nurse

then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated

(if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using

sterile linens) and is placed on NPO status because of the altered gastrointestinal function that

occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the

fluid resuscitation can be carefully monitored. Once these actions are taken the nurse performs a

complete assessment, stays with the client, and monitors the client closely. In addition, tetanus

toxoid may be prescribed for prophylaxis.

A. Smoke inhalation injury

1. Description: Respiratory injury that occurs when the victim inhales products of combustion

during a fire.

The airway is a priority concern in an inhalation injury.

2. Assessment

a. Facial burns

b. Erythema

c. Swelling of oropharynx and nasopharynx

d. Singed nasal hairs

e. Flaring nostrils

f. Stridor, wheezing, and dyspnea

g. Hoarse voice

h. Sooty (carbonaceous) sputum and cough

i. Tachycardia

j. Agitation and anxiety

B. Carbon monoxide poisoning

1. Description

a. Carbon monoxide is a colorless, odorless, and tasteless gas that has an affinity for

hemoglobin 200 times greater than that of oxygen.

b. Oxygen molecules are displaced and carbon monoxide reversibly binds to hemoglobin to

form carboxyhemoglobin.

c. Tissue hypoxia occurs.

2. Assessment

Blood Level (%) Clinical Manifestations

1-10% Normal level

11-20% (mild poisoning)

Headache

Flushing

Decreased visual acuity

Decreased cerebral functioning

Slight breathlessness

21-40% (moderate poisoning)

Headache

Nausea and vomiting

Drowsiness

Tinnitus and vertigo

Confusion and stupor

Pale to reddish-purple skin

Decreased blood pressure

Increased and irregular heart rate

41-60% (severe poisoning) Coma

Seizures

61-80% (fatal poisoning) Death

C. Direct thermal heat injury

1. Description

a. Thermal heat injury can occur to the lower airways by the inhalation of steam or explosive

gases or the aspiration of scalding liquids.

b. Injury can occur to the upper airways, which appear erythematous and edematous, with

mucosal blisters and ulcerations.

c. Mucosal edema can lead to upper airway obstruction, especially during the first 24 to 48

hours.

d. All clients with head or neck burns should be monitored closely for the development of

airway obstruction and are considered immediately for endotracheal intubation if obstruction

occurs.

2. Assessment

a. Erythema and edema of the upper airways

b. Mucosal blisters and ulcerations

A. Following a burn, vasoactive substances are released from the injured tissue, and these substances

cause an increase in capillary permeability, allowing the plasma to seep into the surrounding

tissues.

B. The direct injury to the vessels increases capillary permeability (capillary permeability decreases

18 to 26 hours after the burn, but does not normalize until 2 to 3 weeks following injury).

C. Extensive burns result in generalized body edema and a decrease in circulating intravascular

blood volume.

D. The fluid losses result in a decrease in organ perfusion.

E. The heart rate increases, cardiac output decreases, and blood pressure drops.

F. Initially, hyponatremia and hyperkalemia occur.

G. The hematocrit level increases as a result of plasma loss; this initial increase falls to below

normal by the third to fourth day after the burn as a result of red blood cell damage and loss at the

time of injury.

H. Initially, the body shunts blood from the kidneys, causing oliguria; then the body begins to reabsorb

fluid, and diuresis of the excess fluid occurs over the next days to weeks.

I. Blood flow to the gastrointestinal tract is diminished, leading to intestinal ileus and gastrointestinal

dysfunction.

J. Immune system function is depressed, resulting in immunosuppression and thus increasing the risk

of infection and sepsis.

K. Pulmonary hypertension can develop, resulting in a decrease in the arterial oxygen tension level

and a decrease in lung compliance.

L. Evaporative fluid losses through the burn wound are greater than normal, and the losses continue

until complete wound closure occurs.

M. If the intravascular space is not replenished with intravenously administered fluids, hypovolemic

shock and ultimately death occur.

Resuscitation/Emergent Phase

Begins at the time of injury Ends with the restoration of normal capillary permeability Duration usually 48 to 72 hr Includes prehospital care and emergency department care

The primary goal is to maintain a patent airway, administer intravenous fluids to prevent hypovolemic shock, and preserve vital organ functioning.

Resuscitative Phase

Begins with the initiation of fluids Ends when capillary integrity returns to near-normal levels and large fluid shifts have decreased

The goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion.

Amount of fluid administered is based on client’s weight and extent of injury

(Most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital)

Acute Phase

Begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun The emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved.

Usually, begins 48 to 72 hr after time of injury

Focus on infection control, wound care, wound closure, nutritional support, pain management, physical therapy

Rehabilitative Phase

Overlaps acute phase of care Extends beyond hospitalization The goals of this phase are designed so that the client can gain independence and achieve maximal function.

1. Prehospital care

a. Begins at the scene of the accident and ends when emergency care is obtained.

b. Remove the victim from the source of the burn.

c. Assess the ABCs—airway, breathing, and circulation.

d. Assess for associated trauma, including inhalation injury.

e. Conserve body heat.

f. Cover burns with sterile or clean cloths.

g. Remove constricting jewelry and clothing.

h. Insert intravenous (IV) access.

i. Transport to the emergency department.

2. Emergency department care is a continuation of care administered at the scene of the injury.

3. Major burns

a. Evaluate the degree and extent of the burn and treat life-threatening conditions.

b. Ensure a patent airway and administer 100% oxygen as prescribed.

c. Monitor for respiratory distress and assess the need for intubation.

d. Assess the oropharynx for blisters and erythema; assess vocal quality and for singed nasal

hairs and auscultate lung sounds.

e. Monitor arterial blood gases and carboxyhemoglobin levels.

f. For an inhalation injury, administer 100% oxygen via a tight-fitting nonrebreather face mask

as prescribed until the carboxyhemoglobin level falls below 15%.

g. Initiate peripheral IV access to nonburned skin proximal to any extremity burn, or prepare for

the insertion of a central venous line as prescribed.

h. Assess for hypovolemia and prepare to administer fluids intravenously to maintain fluid

balance.

i. Monitor vital signs closely.

j. Insert a Foley catheter as prescribed, and maintain urine output at 30 to 50 mL/hour.

k. Maintain NPO status.

l. Insert a nasogastric tube as prescribed to remove gastric secretions and prevent aspiration.

m. Administer tetanus prophylaxis as prescribed.

n. Administer pain medication, as prescribed, by the IV route.

o. Prepare the client for an escharotomy or fasciotomy as prescribed.

4. Minor burns

a. Administer pain medication as prescribed.

b. Instruct the client in the use of oral analgesics as prescribed.

c. Administer tetanus prophylaxis as prescribed.

d. Administer wound care as prescribed, which may include cleansing, debriding loose tissue,

and removing any damaging agents, followed by the application of topical antimicrobial

cream and a sterile dressing.

e. Instruct the client in follow-up care, including active range-of-motion exercises and wound

care treatments.

1. Fluid resuscitation

a. The amount of fluid administered depends on how much IV fluid per hour is required to

maintain a urinary output of 30 to 50 mL/hour.

b. Successful fluid resuscitation is evaluated by stable vital signs, an adequate urine output,

palpable peripheral pulses, and intact level of consciousness and thought processes.

c. IV fluid replacement may be titrated (adjusted) on the basis of urinary output plus serum

electrolyte levels to meet the perfusion needs of the client with burns.

d. If the hemoglobin and hematocrit levels decrease or if the urinary output exceeds 50 mL/hour,

the rate of IV fluid administration may be decreased.

Urinary output is the most reliable and most sensitive noninvasive assessment parameter

for cardiac output and tissue perfusion.

2. Interventions

a. Monitor for tracheal or laryngeal edema and administer respiratory treatments as prescribed.

b. Monitor pulse oximetry and prepare for arterial blood gases and carboxyhemoglobin levels if

inhalation injury is suspected.

c. Elevate the head of the bed to 30 degrees or more for burns of the face and head.

d. Initiate electrocardiographic monitoring.

e. Monitor temperature and assess for infection.

f. Initiate protective isolation techniques; maintain strict hand washing; use sterile sheets and

linens when caring for the client; and use gloves, cap, masks, shoe covers, scrub clothes, and

plastic aprons.

g. Clip body hair around wound margins.

h. Monitor daily weights, expecting a weight gain of 15 to 20 pounds in the first 72 hours.

i. Monitor gastric output and pH levels and for gastric discomfort and bleeding, indicating a

stress ulcer.

j. Administer antacids, H2 receptor antagonists, and antiulcer medications as prescribed to

prevent a stress ulcer.

k. Auscultate bowel sounds for ileus and monitor for abdominal distention and gastrointestinal

dysfunction.

l. Monitor stools for occult blood.

m. Obtain urine specimen for myoglobin and hemoglobin levels.

n. Monitor IV fluids and hourly intake and output to determine the adequacy of fluid replacement

therapy; notify the HCP if urine output is less than 30 or greater than 50 mL/hour.

o. Elevate circumferential burns of the extremities on pillows above the level of the heart to

reduce dependent edema if no obvious fractures are present; diuretics increase the risk of

hypovolemia and are generally avoided as a means of decreasing edema.

p. Monitor pulses and capillary refill of the affected extremities and assess perfusion of the

distal extremity with a circumferential burn.

q. Prepare to obtain chest x-rays and other radiographs to rule out fractures or associated

trauma.

r. Keep the room temperature warm.

s. Place the client on an air-fluidized bed or other special mattress and use a bed cradle to keep

sheets off the client’s skin.

3. Pain management

a. Administer opioid analgesics as prescribed by the IV route.

b. Avoid administering medication by the oral route because of the possibility of gastrointestinal

dysfunction.

c. Medicate the client as prescribed and before painful procedures.

Avoid the intramuscular or subcutaneous medication route for medication administration

because absorption through the soft tissue is unreliable when hypovolemia and large fluid

shifts occur.

4. Nutrition

a. Proper nutrition is essential to promote wound healing and prevent infection.

b. The basal metabolic rate is 40 to 100 times higher than normal with a burn injury.

c. Maintain NPO status until bowel sounds are heard, and then advance to clear liquids as

prescribed.

d. Nutrition may be provided via enteral tube feeding or parenteral nutrition through a central

line.

e. Provide a diet high in protein, carbohydrates, fats, and vitamins.

f. Monitor calorie intake.

5. Escharotomy

a. A lengthwise incision is made through the burn eschar to relieve constriction and pressure

and to improve circulation.

b. Escharotomy is performed for circulatory compromise caused by circumferential burns.

c. Escharotomy is performed at the bedside without anesthesia because nerve endings have been

destroyed by the burn injury.

d. Escharotomy can be performed on the thorax to improve ventilation.

e. Following the escharotomy, assess pulses, color, movement, and sensation of affected

extremity and control any bleeding with pressure.

f. Pack the incision gently with fine mesh gauze as prescribed after escharotomy.

g. Apply topical antimicrobial agents to the area as prescribed.

6. Fasciotomy

a. An incision is made extending through the subcutaneous tissue and fascia.

b. The procedure is performed if adequate tissue perfusion does not return following an

escharotomy.

c. Fasciotomy is performed in the operating room with the client under general anesthesia.

d. Following the procedure, assess pulses, color, movement, and sensation of affected extremity

and control any bleeding with pressure.

e. Apply topical antimicrobial agents and dressings to the area, as prescribed.

Acute phase

Burns

1. Continue with protective isolation techniques.

2. Provide wound care as prescribed and prepare for wound closure.

3. Provide pain management.

4. Provide adequate nutrition as prescribed.

5. Prepare the client for rehabilitation.

D. Wound care

1. Description: Cleansing, debridement, and dressing of burn wounds

2. Hydrotherapy

a. Wounds are cleansed by immersion, showering, or spraying.

b. Hydrotherapy occurs for 30 minutes or less to prevent increased sodium loss through the burn

wound, heat loss, pain, and stress.

c. Client should be premedicated before procedure.

d. Hydrotherapy generally is not used for clients who are hemodynamically unstable or those

with new skin grafts.

e. Care is taken to minimize bleeding and maintain body temperature during the procedure.

f. If hydrotherapy is not used, wounds are washed and rinsed with the client in bed before the

application of antimicrobial agents.

3. Debridement

Mechanical

■ Performed during hydrotherapy; involves use of washcloths or sponges to cleanse and debride

eschar and the use of scissors and forceps to lift and trim away loose eschar

■ May include wet-to-dry or wet-to-wet dressing changes

■ Painful procedure; may cause bleeding

Enzymatic

■ Application of topical enzyme agents directly to the wound; the agent digests collagen in necrotic

tissue

Surgical

■ Excision of eschar or necrotic tissue via a surgical procedure in the operating room

Tangential Technique

■ Very thin layers of the necrotic burn surface are excised until bleeding occurs (bleeding indicates

that a healthy dermis or subcutaneous fat has been reached).

Fascial Technique

■ The burn wound is excised to the level of superficial fascia; this technique is usually reserved

for very deep and extensive burns.

a. Debridement is removal of eschar or necrotic tissue to prevent bacterial proliferation under

the eschar and to promote wound healing.

b. Debridement may be mechanical, enzymatic, or surgical.

c. Deep partial-thickness burns or deep full-thickness burns: Wound is cleansed and debrided,

and topical antimicrobial agents are applied once or twice daily.

E. Wound closure

1. Description

a. Wound closure prevents infection and loss of fluid.

b. Closure promotes healing.

c. Closure prevents contractures.

d. Wound closure is performed usually on day 5 to 21 following the injury, depending on the

extent of the burn.

2. Wound coverings

Biological

Amniotic Membranes

■ Amniotic membrane from human placenta is used; adheres to the wound

■ Effective as a dressing until epithelial cell regrowth occurs

■ Requires frequent changes because it does not develop a blood supply and disintegrates in about

48 hours

Allograft or Homograft (Human Tissue)

■ Donated human cadaver skin provided through a skin bank

■ Monitor for wound exudate and signs of infection

■ Rejection—can occur within 24 hours

■ Risk of transmitting blood-borne infection exists when used

Xenograft or Heterograft (Animal Tissue)

■ Pigskin harvested after slaughter is preserved for storage and use.

■ Monitor for infection and wound adherence

■ Placed over granulation tissue; replaced every 2 to 5 days until wound heals naturally or until

closure with autograft is complete.

Cultured Skin

■ Grown in laboratory from a small specimen of epidermal cells from an unburned portion of

client’s body

■ Cell sheets are grafted on the client to generate permanent skin surface.

■ Cell sheets are not durable; care must be taken when applying to ensure adherence, and prevent

sloughing.

Artificial Skin

■ Consists of two layers—Silastic epidermis and porous dermis made from bovine hide collagen

and shark cartilage

■ After application, fibroblasts move into the collagen part of the artificial skin and create a

structure similar to normal dermis.

■ Artificial dermis then dissolves; it is then replaced with normal blood vessels and connective

tissue called neodermis.

■ Neodermis supports the standard autograft placed over it when the Silastic layer is removed.

Biosynthetic

■ Combination of biosynthetic and synthetic materials

■ Placed in contact with the wound surface; forms an adherent bond until epithelialization occurs

■ Porous substance allows exudate to pass through.

■ Monitor for wound exudate and signs of infection.

Synthetic

■ Applied directly to the surface of a clean or surgically prepared wound; remains in place until it

falls off or is removed

■ Covering is transparent or translucent; therefore wound can be inspected without removing

dressing.

■ Pain at the wound site is reduced because covering prevents contact of the wound with air.

Autograft

■ Skin taken from a remote unburned area of client’s own body; transplanted to cover burn wound

■ Graft placed on a clean granulated bed or over surgically excised area of the burn

■ Provides for permanent skin coverage

3. Autografting

a. Autografting provides permanent wound coverage.

b. Autografting is the surgical removal of a thin layer of the client’s own unburned skin, which

then is applied to the excised burn wound.

c. Autografting is performed in the operating room under anesthesia.

d. Monitor for bleeding following the graft procedure because bleeding beneath an autograft can

prevent adherence.

e. If prescribed, small amounts of blood or serum can be removed by gently rolling the fluid

from the center of the graft to the periphery with a sterile gauze pad, where it can be

absorbed.

f. For large accumulations of blood, the HCP may aspirate the blood using a small-gauge needle

and syringe.

g. Autografts are immobilized following surgery for 3 to 7 days to allow time to adhere and

attach to the wound bed.

h. Position the client for immobilization and elevation of the graft site to prevent movement and

shearing of the graft.

4. Care of the graft site

a. Elevate and immobilize the graft site.

b. Keep the site free from pressure.

c. Avoid weight-bearing.

d. When the graft takes, if prescribed, roll a cotton-tipped applicator over the graft to remove

exudate, because exudate can lead to infection and prevent graft adherence.

e. Monitor for foul-smelling drainage, increased temperature, increased white blood cell count,

hematoma formation, and fluid accumulation.

f. Instruct the client to avoid using fabric softeners and harsh detergents in the laundry.

g. Instruct the client to lubricate the healing skin with prescribed agents.

h. Instruct the client to protect the affected area from sunlight.

i. Instruct the client to use splints and support garments as prescribed.

5. Care of the donor site

a. Method of care varies, depending on the HCP’s preference.

b. A nonadherent gauze dressing may be applied at the time of the surgery to maintain pressure

and stop any oozing; always check surgeon’s preference.

c. The HCP may prescribe site treatment with gauze impregnated with petrolatum or with a

biosynthetic dressing.

d. Keep the donor site clean, dry, and free from pressure.

e. Prevent the client from scratching the donor site.

f. Apply lubricating lotions to soften the area and reduce the itching after the donor site is

healed.

g. Donor site can be reused once healing has occurred (heals spontaneously within 7 to 14 days

with proper care).

F. Physical therapy

1. An individualized program of splinting, positioning, exercises, ambulation, and activities of

daily living is implemented early in the acute phase of recovery to maximize functional and

cosmetic outcomes.

2. Perform range-of-motion exercises as prescribed to reduce edema and maintain strength and

joint function.

3. Ambulate the client as prescribed to maintain the strength of the lower extremities.

4. Apply splints as prescribed to maintain proper joint position and prevent contractures.

a. Static splints immobilize the joint and are applied for periods of immobilization, during

sleeping, and for clients who cannot maintain proper positioning.

b. Dynamic splints exercise the affected joint.

c. Avoid pressure to skin areas when applying splints, which could lead to further tissue and

nerve damage.

5. Scarring is controlled by elastic wraps and bandages that apply continuous pressure to the

healing skin during the time in which the skin is vulnerable to shearing.

6. Anti–burn scar support garments are usually prescribed to be worn 23 hours a day until the burn

scar tissue has matured, which takes 18 to 24 months.

Rehabilitative phase

Burns

1. Description: Rehabilitation is the final phase of burn care.

2. Goals

a. Promote wound healing.

b. Minimize deformities.

c. Increase strength and function.

d. Provide emotional support.

A. Description

1. A chronic inflammatory skin disease that is also known as eczema and is characterized by dry

and scaly skin.

2. May be treated with moisturizer and topical glucocorticoids; systemic immunosuppressants may

also be prescribed if topical treatment is ineffective.

3. Systemic immunosuppressants may include methotrexate, cyclosporine (Sandimmune), or

azathioprine (Imuran), and oral glucocorticoids.

B. Topical immunosuppressants

1. Tacrolimus (Protopic 0.03% or 0.1% cream) and pimecrolimus 1% cream (Elidel).

2. Side/adverse effects include redness, burning, and itching; causes sensitization of the skin to

sunlight.

3. Tacrolimus increases the risk of varicella-zoster infection in children.

4. Tacrolimus may cause skin cancer and lymphoma.

Medications to Treat Atopic Dermatitis

Systemic Immunosuppressants

■ Azathioprine (Imuran)

■ Cyclosporine (Sandimmune)

■ Methotrexate

■ Oral glucocorticoids

Topical Immunosuppressants

■ Pimecrolimus 1% cream (Elidel)

■ Tacrolimus (Protopic)