Burn Wound Care: Opened Method vs. Closed Method

Opened Wound Care

The antimicrobial cream is applied every 12 hours and wound is left open to the air without any dressing.

Advantages:
The wound can easily visualized, easier mobility and joint range of motion, and simplicity in wound care.

Disadvantages:
Increase chance of hypothermia from exposure.

Closed Wound Closure

Gauze dressings are wrapped carefully from the distal to the proximal are of the extremity to ensure circulation is not compromised. The dressings are changes every 8-12 hours.

Advantages:
Using this method will decreases evaporative fluid, decreases heat loss and aids in debridement.

Disadvantages:
The disadvantages of this method are mobility limitation, prevents effective range of motion exercises, and limited of wound assessment.

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Burn Wound Care: Wound Closure

Wound closure of burn area is performed on the fifth to twenty-first day. It is depend on the extent of the burn area. Wound closure can prevent infection and loss of fluid, promotes healing and prevents contractures.

There are two types of wound closure techniques: temporary wound covering and permanent wound covering (autografting).

Temporary Wound Covering

1. Biological

Amnion:
The amniotic membranes from human placenta are used, and dressing is changes every 48 hours with amnion.

Allograft Homograft:
The donated human cadaver skin is used. Extra monitor for wound, sign of infection and sign of rejection. The rejection can occur within 24 hours.


Xenograft Heterograft
Xenograft over granulation tissue is replaced every 2 to 5 days until the wound heals naturally or until closure with autograft is complete.

Biosynthetic and Synthetic
Visual infection of wound is possible because dressing are transparent or translucent. Wound exudates and signs of infection should be monitored.

2. Autografting
Autografting is surgical removal of a thin layer of the client’s unburn skins, which then is applied to the excised burn wound that provide permanent wound coverage. This procedure is performed in the operating room under anesthesia. Bleeding following the graft should be monitored because bleeding beneath an autograft can prevent adherent. Autograft areas are immobilized 3 to 7 days following surgery to allow time to adhere and attach to the wound bed.

There are four types of skin grafts:

• Split Thickness: Graft of half of the epidermis, applied in sheets or postage stamp-like pieces.
• Full Thickness: Graft consisting of epidermis and dermis are used for reconstructive surgery months or years after the initial surgery.
• Pedicle Flap: This is used for reconstructive surgery months or years after the initial inury.
• Cultured Epithelium: The client’s unburned skin is used. Isolation of keratinocytes and culturing of epithelial cells in a laboratory and then are attached to the burn wound.

CARE TO THE GRAFT SITE:

1. Immobilize and elevate graft site and keep from pressure.
2. Avoid weight bearing
3. Remove exudates (if any) using roll a cotton-tipped applicator over the graft to prevent infections.
4. Monitor for foul-smelling drainage, increased temperature, fluid accumulation, hematoma, and increased WBC.
5. Instruct the client to lubricate healing skin with cocoa butter as prescribed, avoid using fabric softeners and harsh detergents in the laundry, protect the affected area from sunlight, and use splints and support garment as prescribed.

CARE FOR THE DONOR SITE:

• The methods of care for the donor site may varies depending on physician’s preference.
• A moist gauze dressing is applied at the time of the surgery to maintain pressure and stop any oozing.
• Keep the donor site clean, dry, and free from pressure.
• Apply lubricating lotions to soften the area and reduce the itching.
• Prevent the client from scratching the donor site.

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Burn Wound Care: Hydrotherapy and Debridement

HYDROTHERAPY

Burn wound area are cleansed by immersion, showering or spraying and no more than 30 minutes to prevent increased sodium loss through the burn wound, heat loss, pain, and stress. Client should be premedicated before procedure. Bleeding should be minimize and maintain body temperature during procedure.

Hydrotherapy generally is not use for patients who are unstable or those with ne skin grafts. So if hydrotherapy is not use, burn wound areas are washed and rinsed in bed before the application of antimicrobial agents.

DEBRIDEMENT

Burn Debridement means the excision of devitalized tissue and foreign matter from burn wound area. It can prevent bacterial proliferation and promote wound healing. Debridement may be mechanical, enzymatic, or surgical.

Mechanical:
This mechanical technique uses scissor and forceps to lift and trim away loose eschar. It is a painful procedure and may be bleeding and requires a moist environment to be effective. Dressings are applied directly to the burn wound area: wet-to-dry or wet-to-wet dressing technique.

Enzymatic:
Enzymatic technique means using prepared proteolytic and fibrinolytic topical enzymes that digest necrotic tissue, which facilitates eschar removal.

Surgical:
The eschar area is excised and covered. It may be tangential (shaving of thin layers of eschar until viable tissue is reached) or fascial (used for deep burns and removal of burn tissue and underlying fat down to the fascia).

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Inhalation Injuries

There are four types of inhalation injury that most occurred: Smoke inhalation injury, carbon monoxide poisoning, smoke poisoning, and direct thermal heat injury.

Smoke Inhalation Injury
Smoke inhalation injury is occurred when the person is trapped in an enclosed, hot, smoke filled space. Patient with smoke inhalation might be have facial burns, erythema, swelling of oropharynx and nasopharynx, flaring nostrils, hoarse voice, stridor, wheezing, dyspnea, sooty (carbonaceous sputum), cough and tachycardia.


Carbon Monoxide Poisoning
Carbone monoxide is a colorless, practically odorless, and poisonous gas formed by the incomplete combustion of carbon; its toxic action is due to its strong affinity for hemoglobin, myoglobin, and the cytochromes, reducing oxygen transport and blocking oxygen utilization.
Oxygen molecules are displaced and carbon monoxide reversibly binds to hemoglobin to form carboxyhemoglobin that tissue will be hypoxia.

The signs and symptom of carbon monoxide poisoning are depended on the level of carbon monoxide in blood. It will be from impaired visual activity, headache, nausea, vomiting, dizziness, syncope, tachypnea, tachycardia, until coma or death.

Smoke Poisoning
Smoke poisoning is injury result when the victim inhales by-products of combustion. The localized inflammatory reaction occurs that causing a decrease in bronchial ciliary action and decrease in surfactant. The victim will have mucosal edema and wheezing.

Direct Thermal Heat Injury
Direct thermal heat injury can occur to the lower or upper airways by the inhalation of steam or explosive gases. Mucosal edema can lead to upper airway obstruction especially during the first 24 hours.

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Burn Injury Management

There are four phases of Burn Injury Management: Emergent phase, resuscitative phase, acute phase, and rehabilitative phase.

Emergent Phase

• It includes pre-hospital care and emergency room care and begins at the time of injury till the restoration of capillary permeability.
• Usually 48-72 hours following burn injury.
• The management is to prevent hypovolemic shock and preserve vital organ functioning.

Resuscitative Phase

• The resuscitative phase begins with the initiation of fluids until capillary integrity returns to normal level.
• Administration of fluid is based on the body weight and extent of injury, and the formulas are calculated from the time of injury and not from the time of arrival at the hospital.
• Management of this phase is to prevent shock by maintaining adequate circulating blood volume.

Acute Phase

• This phase begins when the victim is hemodynamically stable, capillary permeability is restored, and diuresis has begun and continues until wound closure is achieved.
• Usually 48-72 after the time of injury.
• Management of this phase focus on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy.

Rehabilitation Phase

• This is final phase of burn management.
• It focuses that the patient can gain independence and achieve maximal function.

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Burn Injuries (Part 3)

Rule of Nines

This method is used in calculating body surface area involved in burns. Here are Rule of Nines (Adult):

• Head and nect: 9%
• Anterior trunk: 18%
• Posterior trunk: 18 %
• Arm (9% each): 18%
• Legs (9% each): 18%
• Perineum: 1%

We can estimate the body surface area on an adult that has been burned by using multiples of 9.
For example, if both legs (18% x 2 = 36%), anterior trunk (18%) and both of arm (18%) were burned, this would involve 72% of the body.

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Burn Injuries (part 1)

A burn injury is a type of injury that may be caused by heat, cold, electricity, chemicals, light, radiation, or friction.

Burn Size:

1. Small burns: Localized burn to the injury area.
2. Large burns: Consist of 25% or more of the total body surface area, and the response is systemic means all of the major systems of the body is affected.

Burn Classification by Depth:

1. Superficial-thickness Burn
It is similar to first-degree burn. There is mild to severe erythema but no blisters. Burn is painfull, and is ceased by cooling. It heals in 3 -7 days.


2. Partial-thickness Superficial Burn
It is similar to second-degree burn. Large blisters cover an extensive area and edema is present. Mottled red base and broken epidermis with a wet, shiny, and weeping surface. Burn is painful and sensitive to cold air. Superficial partial thickness burn heals in 2-3 weeks while the deep partial thickness heals in 3-6 weeks. If the healing process is prolonged, the grafts may be used.

3. Full-thickness Burn
It is similar to third-degree burn. A deep red, black, white, yellow or brown area are present with edema. Burn causes tissue disruption with fat exposed and spontaneous healing will not occur. There is little or no pain of burn area. It requires removal of eschar and split or full thickness skin grafting. The healing will be weeks to months.

4. Deep Full-thickness Burn
It is similar to fourth-degree burn. It involves injury to the muscle and bone. The injured area appears black, no edema, no pain and no blisters. The eschar is hard and inelastic, and healing take weeks to months. Graft are required.

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Decubitus Ulcer

Decubitus ulcer is an impairment of skin integrity when staying in one position for too long without shifting weight. It is also called as bedsore or pressure ulcer. This case often happens when using wheelchair and bedridden. The common places for decubitus ulcer are over bony prominences such as the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

The constant pressure against the skin can reduce the blood supply to that area and will affect tissue dies. It will start as reddened skin and will progressively worse to form a blister, open sore, and a crater. The important thing is to prevent of skin breakdown, particularly in caring or the bedridden or immobile patient.

There are factors that increase the risk for decubitus ulcer:

• elderly
• inability to move parts of body
• malnourishment
• bedridden or wheelchair patient
• chronic condition (diabetes or vascular disease)
• urinary or bowel incontinence
• fragile skin, and
• mental disability.

Stage of Decubitus Ulcers:

STAGE 1
Ulcer is a reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief. The skin still intact and the red area does not blanch with external pressure.

STAGE 2
The top layer of skin is missing. The ulcer is shallow with a pink to red base and white or yellow eschar may be present.

STAGE 3
The ulcer extends into the dermis and subcutaneous tissues, white, gray or yellow eschar is present. Purulent drainage is common.

STAGE 4
The ulcer extends into muscle and bone, four smelling with brown or black eschar, and purulent drainage is common.

Care for Decubitus Ulcer:

• Prevent the position that promote pressure.
• Assess the nutritional status.
• Adequate nutritional intake to promote tissue integrity.
• Remove any pressure on the skin.
• Turn and preposition the bedridden patient every two hours or more if necessary.
• Active and passive exercises every 8 hours.
• Keep the skin clean and dry.
• Use moisture barrier if needed as prescribed.
• Use an alternating air pressure mattress or sheep skin padding.
• Wound dressing and medications as prescribed.

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Acne Vulgaris

Acne Vulgaris is a skin condition characterized by whiteheads, blackheads, and inflamed red pimples. And there are types of lesions include comedones, pustules, papules, and nodules. It requires active treatment for control until it resolves.

The exact cause is unknown but may include:

• Androgenic influence on sebaceous glands,
• Increased sebum production,
• Proliferation of propionibacterium acnes,
• Oil cosmetics and hair products,
• Drugs such as steroids, testosterone, estrogen, and phenytoin,
• Sweating and high level of humidity.
• The exacerbation of acne vulgaris is coincided with the menstrual cycle from hormonal activity.

Acne vulgaris is commonly appeared on the face and shoulders, trunk, arms, legs, and buttocks, and mostly in teenagers.

Cares for person with acne vulgaris are:

1. Topical or oral antibiotic as doctor prescribed.
2. Isotretinoin (Accutane) to inhibit sebum production and reduce sebaceous gland size.
3. Tell the client about the adverse effects of isotretinoin that include cheilitis (lip inflammation), skin dryness, triglycerides elevation, and eye discomfort.
4. Avoid taking vitamin A during treatment with isotretinoin
5. Appropriate skin cleansing methods (not scrubbing the face, using only the agreed on topical agents)
6. Not to squeeze, pick or prick at lesions.
7. Use cosmetics that are water-based and avoid contact with excessive oil-base products.

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Frostbite

Frostbite is local tissue destruction resulting from prolonged exposure to extreme cold. In mild cases, frostbite will result in superficial, reversible freezing followed by erythema and slight pain. In severe cases it can be numbness, paresthesia, painless and result in blistering, persistent edema and gangrene. Fingers, toes, nose and ears are the areas often affected.

Medical or nursing intervention of frostbite will include:

• Handle the tissue gently.
• Rewarm the affected area rapidly with a warm water bath (90o to 107o F) in 15 to 20 minutes or until the skin flushes.
• Avoid massage.
• Do not debride blisters.
• Apply bulky dressing as prescribed to provide protection.

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Impetigo

Impetigo is a contagious superficial pyoderma, caused by Staphylococcus aureus and/or group A streptococci, that begins with a superficial flaccid vesicle that ruptures and forms a thick yellowish crust, most commonly occurring in children.

The most common sites of infection are the face, around the mouth, the hands, the neck, and the extremities. The lesions begin as vesicles or pustules surrounded by edema and redness and progresses to an exudative and crusting stage. And after crusting, the initially serous vesicular fluid becomes cloudy and ruptures. It makes a honey-colored crust covering an ulcerated base.

Persons with impetigo will have specific signs:

1. Pruritus
2. Lesions
3. Burning
4. Lymph node involvement

How to care person with impetigo?

Here are the guidelines:

• Use standard precautions and implement agency specific isolation procedures in relation with impetigo.
• Let lesions to dry by air exposure.
• Daily bathing with antibacterial soap such as pHisoHex.
• Warm compresses to lesions 2 or 3 times per day to remove crusts and healing.
• Oral antibiotic for impetigo as prescribed.
• Use emollients to prevent skin cracking.
• Frequent hand washing when caring person with impetigo, to prevent the spread of infection.
• Use separate towels, linens, and dishes.
• All linens and clothing should be washed separately with detergent in hot water.

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Paronychia

Paronychia is a suppurative inflammation of the nail fold surrounding the nail plate; may be due to bacteria or fungi, most commonly staphylococci and streptococci. It most commonly occurs in middle-aged women and in the client with diabetes mellitus.

Person who has paronychia will have painful, redness and swelling around the nailbed, and soreness at nailbed. There may be pus-filled blisters, especially with a bacterial infection. Because of paronychia, the nail may look detached, abnormally shaped, or have an unusual color.



There are three types of paronychia :

1. Bacterial paronychia that is caused by bacteria.
2. Candidal paronychia that is caused by a specific type of yeast.
3. Fungal paronychia that is caused by a fungus other than Candida.

Nursing Intervention for paronychia:

• Monitor temperature
• Monitor for infection around the nails
• Monitor for cellulitis in the affected area
• Soaking the nail in hot water 2 or 3 times a day helps reduce inflammation and pain
• Incision and drainage of infected area if prescribed
• Antibiotic and fungicidal ointments as prescribed

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Kaposi’s Sarcoma

Kaposi’s Sarcoma is a multifocal malignant neoplasm that occur primarily in individuals with a compromised immune system such as AIDS. It is clinically manifested by cutaneous lesions consisting of reddish-purple to dark-blue macules, plaques, or nodules, that seen most commonly in men over 60 years of age.

Kaposi’s sarcoma may first appear on the feet or ankles, thighs, arms, hands, or face. Organ involvement includes the lymph nodes, airways or lungs, or any part of the gastrointestinal tract from the mouth to anus. So person has Kaposi’s Sarcoma may also has bleeding from gastrointestinal lesions, shortness of breath from lesion in the lung, and bloody sputum from lesions in the lung. Refer to images (end of this article)

Treatment of Kaposi’s sarcoma will depend on the extent and location of the lesions, person’s symptoms, and degree of immunosuppression. Radiation therapy, cryotherapy or chemotherapy also may be used for lesions in certain areas.

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Psoriasis

Psoriasis is a chronic noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches, characterized by the eruption of circumscribed, discrete and confluent, reddish, silvery-scaled maculopapules. The lesions occur predominantly on the elbows, knees, scalp, and trunk.

Psoriasis most commonly begins between ages 15 and 35 and it can appear suddenly or slowly.

Type of Psoriasis
There are five main types of psoriasis.

1. Erythrodermic: The skin is redness and covers a large area.
2. Guttate: The skin appears small, pink-red spots.
3. Inverse: Skin redness and irritation occurs in the armpits, groin, and in between overlapping skin.
4. Plaque: Thick, red patches of skin are covered by flaky, silver-white scales. This is the most common type of psoriasis.
5. Pustular: White blisters are surrounded by red, irritated skin.

Symptoms:

• Pruritus
• Shedding, silvery, white scales on a raised, reddened, round plaque that mostly affects the scalp, knees, elbows, extensor surface of arms and legs, and sacral regions.
• A yellow discoloration, pitting, and a thickening of nails if they are affected.
• Joint inflammation with psoriatic arthritis.

Please see images on the end of this post/article!

Nursing Intervention:

• Administer daily soaks and tepid, wet compresses to the affected areas to remove scales.
• Assist the client to remove the scales during the soak.
• Occlusive dressing may be applied following application of corticosteroid to increase its effectiveness
• Plastic wrap or bags can be used as occlusive dressing.
• Instruct the client not to scratch the affected areas and to keep the skin lubricated to minimize itching
• Encourage client to wear light cotton clothing over affected areas.
• Instruct the client to be consistent regarding prescribed treatment and avoid over the counter medications.

click image to enlarge

Treatment for psoriasis can be intralesional therapy (injection of triamcinolone acetonide, aristocort, kenlog-10, trymex), systemic therapy (methotrexate, hydroxyurea, and cyclosporine A), and photochemotherapy.

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LYME DISEASE

Lyme disease is a subacute inflammatory disorder caused by infection with Borrelia burgdorferi, a nonpyogenic spirochete transmitted by Ixodes scapularis (see image the end of this article), the deer tick bite, in the eastern U.S. and I. pacificus, the western black-legged tick, in the western U.S. Ticks live in wooded area and survive by attaching to a host. And tick nymphs are thought to be responsible for about 90% of transmission to human beings.

Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. Variations in clinical features or severity from one patient to another may be due to inborn variations in immune response, perhaps linked to the human lymphocytic antigen system. The specific symptoms are depend on stages.

First Stage : Early localized infection

• Symptoms occur several days to month following the bite.
• Flulike symptoms
• Small red pimple that becomes ring-shaped rash (see image on the end of this article), and it can be large or small

Second Stage: Early disseminated infection

• Symptoms occurs several week following the bite.
• Neurological complication
• Joint pain
• Cardiac complication

Third Stage: Late persistent infection

• Large joints becomes involved
• Arthritis progresses

CARE INTERVENTIONS:

1. Remove the tick with tweezers gently, wash skin with antiseptic.
2. Take a blood test for 4 – 6 weeks following a bite to detect the presence of lyme disease.
3. Antibiotics as prescribed if the lyme disease is confirmed.
4. Avoid area that contain ticks (wood area, grassy area) especially in summer.
5. Wear long-sleeved tops long pants, close shoes and hat while outside
6. It is recommended to spray the body with tick repellent before going outside.

Images are here :


ring-shaped rash



Ixodes scapularis, the primary vector of Lyme disease in eastern North America




Nymphal and adult deer ticks can be carriers of Lyme disease.

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POISON IVY, OAK AND SUMAC

This is a dermatitis that develops from contact with uroshiol from poison ivy, oak, or sumac plant. Poison ivy, oak and sumac are most common allergy in the country claiming half the population and sensitivity to uroshiol can develop at any time. And a person who contacts with ivy, oak or sumac appears to react slightly different to all the remedies.

Assessment :

• Papulovesicular lesions
• Severe itching

How is the nursing intervention?

When a person is suspected contact with poison ivy, oak or sumac, do these steps:

• Cleanse the skin of the plant oils
• Apply cool, wet dressing with Burow’s solution to relieve itching
• Apply lotion or topical corticosteroid as prescribed, and
• Oral corticosteroid for severe reaction as prescribed

Pictures of Ivy :



Pictures of Oak :


Pictures of Sumac :

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Contact Dermatitis

Contact dermatitis is an inflammatory response of the skin that produces skin changes after contact with a specific allergen (allergic contact dermatitis) or irritant (nonallergic contact dermatitis). It is also called a T lymphocyte-mediated dermatitis (type IV hypersensitivity).

Specific allergen that cause contact dermatitis in many people include "poisonous" plants such as poison ivy, certain foods, some metals, cleaning solutions, detergents, cosmetics, perfumes, industrial chemicals, and latex rubber.

A person who has contact dermatitis will get sign and symptom of pruritus and burning, erythema at the point of contact, edema, vesicles with drainage, as well as sign of infection.


Nursing intervention for client with diagnose of contact dermatitis will include :

• Elevation the extremity to reduce edema
• Maintaining a cool environment
• Apply cool and wet dressing and tepid bath
• Protection of the affected area from trauma
• Prevention of scratching and rubbing of the affected area
• Assisting with skin testing to determine allergen
• Encourage client to avoid contact with the allergen and harsh soaps
• Encourage client to avoid using heating pads or blankets
• Administering (as prescribed) antibiotic, antipruritic, antihistamine, and corticosteroids.

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NCLEX - CGFNS : Skin Cancer

Skin cancer is a malignant lesion of the skin which may or may not metastasize. Skin cancer can be caused by chronic friction and irritation to the skin area and exposure to ultraviolet.

Skin cancer can be diagnosed by a skin biopsy that is positive for cancer cell.

There is three types of skin cancer: basal cell, squamous cell, and malignant melanoma. Basal cell is the most common type, arises from the basal cell contained in the epidermis. Squamous cell cancer is the second most common of skin cancer that is a tumor of the epidermal keratinocytes and can infiltrate surrounding structure, metastasize to lymph nodes and bi subsequently fatal. Malignant melanoma is a cancer of the malanocytes that can metastasize to the brain, lungs, bones, liver and skin. Malignant Melanoma is ultimately fatal.

Skin cancer can be assessed by :

• Pruritus
• Local soreness
• Change in color, size, or shape of lesion
• Waxy nodule
• An Irregular, circular, bordered lesion
• Small, red, nodular lesion
• An oozing, bleeding, crusting lesion.

As a professional nurse, you can instruct client with skin cancer to :

1. Do the preventive measures
2. Monitor for lesion that do not heal
3. Avoid contact with chemical irritants
4. Wear layered clothing and use sunscreening lotions with an appropriate skin protection when outdoors
5. Avoid sun exposure between 11 AM and 3 PM
6. Assist with surgical excision of the lesion as prescribed

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