NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Integumentary System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Burns

Focus topic: Medical–Surgical Nursing

Definition: Destruction of layers of the skin by thermal, chemical, or electrical agents; fire, steam, or radiation.

Medical–Surgical Nursing: Degree of Burn According to Depth

Focus topic: Medical–Surgical Nursing

A. Classified by depth of tissue destruction. Categories are similar to, but not the same as, prior categories of first-, second-, third-, and fourth-degree burns.
B. Superficial, partial-thickness (first-degree).

  • Involves epidermis.
  • Area is red or pink.
  • Moderate pain.
  • Spontaneous healing.

C. Deep, partial-thickness (second-degree).

  • Involves epidermis and dermis to the basal cells.
  • Blistering.
  • Severe pain.
  • Regeneration in 1 month.
  • Scarring may occur.

D . Full-thickness (third-degree).

  • Involves epidermis, dermis, and subcutaneous tissue and may extend to the muscle in severe burns.
  • White, gray, or black in appearance.
  • Absence of pain.
  • Edema of surrounding tissues.
  • Eschar formation.
  • Grafting needed due to total destruction of dermal elements.

E. Full-thickness (fourth-degree) from prolonged exposure to high voltage electrical current.

  • Involves fat, fascia, muscle, and/or bone.
  • Tissue is charred.
  • Depending on body surface area (BSA) of injured and response, client may be in shock.
  • Myoglobinuria (red pigments in the urine) and possible hemolysis.
  • Amputations are likely.
  • Grafting of no benefit given depth and severity of injury.

Extent of Burn
A. Rule of nines—good for rapid estimation of extent of BSA involved.

  • Head and neck 9%
  • Anterior trunk 18%
  • Posterior trunk 18%
  • Arms (9% each) 18%
  • Legs (18% each) 36%
  • Perineum 1%

B. Lund/Browder method.

  • More accurate and appropriate to use when calculating fluid replacement.
  • A chart is necessary to compute percentages assigned to body areas.
  • Percentages vary for different age groups.

C. Palm method.

  • Client with scattered burns may have percentage calculated with this method.
  • Size of client’s palm is 1% of BSA—this percentage is used to assess injury.

D. Fluid replacement formulas.

  • Brooke Army formula—colloids, electrolytes, and glucose first 24 hours.
  • Parkland/Baxter—lactated Ringer’s only first 24 hours; day 2, colloid is added.
  • Consensus formula—lactated Ringer’s solution first 24 hours.
  • Evans formula—colloids, electrolytes, and glucose first 24 hours.

E. Associated factors that determine seriousness of burn.

  • Age.
    a. Younger than 18 months.
    b. Older than 65 years.
  • General health.
  • Site of burn.
  • Associated injuries (fractures).
  • Causative agents.
  • Other medical problems.

Category of Burn Classification
A. Classification according to the percentage of body area destroyed.

  • Major burns: 25% or more of the body has sustained second-degree burn, and 10% has sustained third-degree burn; further complicated by fractures, respiratory involvement, and smoke inhalation. Burns of feet, hands, face, and genitalia.
  • Moderate burns: Less than 10% of the body has sustained third-degree burn, and 15% to 25% has sustained second-degree burn.
  • Minor burns: Less than 15% of the body has sustained second-degree burn, and less than 2% has sustained third-degree burn.

B. Classification according to cause.

  • Thermal burns: flame burns, scalding with hot liquids, or radiation.
  • Chemical burns: strong acids or strong alkali solutions.
  • Electrical burns.
    a. Most serious type of burn.
    b. Body fluids may conduct an electrical charge through body (look for entrance and exit area).
    c. Cardiac arrhythmias may occur; often the cause of immediate death.
    d. Toxins that injure kidneys are created postburn.
    e. Voltage and ampere information important in history taking.

Assessment
A. Assess extent of injury.

  • Assess for superficial burn: involves only reddening of the skin.
  • Assess for partial-thickness burn: skin blisters, regeneration of epithelium without grafting.
  • Assess for full-thickness burn: destruction of most of the epidermal tissue; unable to regenerate without graft.
  • Assess for full thickness that involves fat, fascia, muscle, and/or bone.

B. Assess type of treatment appropriate to extent of burn and how burn occurred.

  • First aid.
    a. Provide comfort and prevent chilling.
    b. Wash area with cool, sterile solution or water if no sterile solution is available.
    c. Cover with a sterile cloth to prevent contamination.
    d. Do not apply any substances until burn is evaluated.
    e. Wash surrounding area thoroughly with mild detergent.
  • Exposed method: No dressing is used so that hard eschar forms, protecting wound from infection. This method is excellent for areas difficult to bandage effectively. Requires isolation and is difficult for a child.
  • Closed method: Sterile occlusive dressing is applied frequently, usually with topical medications. Debridement occurs every time the dressing is changed, preventing a large loss of blood at one time, as when eschar is removed.

C. Continued assessment during acute burn phase.

  • Respiratory status.
  • Fluid status.
  • Vital signs.
  • pH from nasogastric (NG) tube and residual gastric volume; gives data on need for antacid therapy.
  • Pain level and need for pain relief.
  • Wound assessment—color, odor, exudate, eschar, etc.
  • Body weight; need for adjusted caloric intake.
  • Psychosocial response to injury.

Implementation
A. Maintain patent airway. Monitor for tracheal– laryngeal edema.
B. Provide fluid replacement therapy.

  • Resuscitative phase.
    a. First 24 to 48 hours postburn, fluid shifts from plasma to interstitial space.
    b. Potassium levels rise in plasma.
    c. Blood hemoconcentration and metabolic acidosis occur.
    d. Fluid loss is mostly plasma.
    e. Nursing responsibilities.
    (1) Monitor vital signs frequently.
    (2) Monitor urinary output (50 to 100 mL/hr—minimum output 30 mL/hr).
    (3) Give one-half of total fluids in first 8 hours or as ordered. (The first 8 hours starts at the time the burn occurs, not the time the client arrives at the healthcare facility.)
    (4) Notify physician if urine output less than 30 mL/hr, weight gain, jugular vein distention, crackles, or increased arterial pressure.
  • Acute or intermediate phase.
    a. Capillary permeability stabilizes and fluid begins to shift from interstitial spaces to plasma.
    b. Hypokalemia, hypernatremia, hemodilution, and pulmonary edema are potential dangers.
    c. Nursing responsibilities.
    (1) Monitor central venous pressure (CVP).
    (2) Observe lab values.
    (3) Maintain adequate urine output.

C. Assess pain level frequently and relieve pain with morphine sulfate IV as ordered. Give small doses frequently.

D . Prevent infection.

  • Provide aseptic technique and environment.
    a. Use meticulous hand hygiene technique or antiseptic gel before and after client care.
    b. Use clean or sterile gloves.
    c. Use isolation protocol. (See Table 8-7.)
  • Observe for signs of infection, increased temperature and pulse, wound drainage.
  • Provide prophylactic measures: tetanus and antibiotics.

E. Prevent pulmonary complications.

  • Establish and observe for adequate airway.
  • Suction prn.
  • Provide humidified oxygen prn.
  • Teach coughing and deep-breathing.
  • Provide frequent position changes.

F. Establish adequate circulatory volume to prevent shock.

  • Observe for signs of hypovolemia (e.g., thirst, vomiting, increased pulse, decreased blood pressure, and decreased urinary output).
  • Observe for signs of circulatory overload, particularly around the second to fifth days, when fluid in extracellular tissues returns to circulation. There is danger of congestive heart failure.
  • Monitor intravenous fluid therapy.
  • Monitor intake and output.

G. Monitor for complications.

  •  edema.
  • Sepsis.
  • Acute respiratory failure.

H. Promote good body alignment—prevent contractures.

  • Keep body parts in alignment.
  • Elevate burned extremities.
  • Provide active and/or passive range of motion to all joints.

I. Provide adequate nutrition (total parenteral nutrition [TPN] or enteral feedings).

  • Give high-protein, high-caloric diet—goal is to provide positive nitrogen balance.
  • Give nutritional supplements and vitamin/ mineral supplements.
  • Provide small, frequent, and attractive meals.
  • Encourage child, who is frequently anorexic, to eat.

J. Provide adequate heat to maintain temperature.
K. Administer antacids, H2-receptor antagonists, and Carafate (sucralfate) to prevent stress ulcer, as ordered.
L. Maintain wound dressings.

  • Initial excision: mainly for electrical burns.
  • Occlusive dressings.
    a. Painful and costly.
    b. Decrease water loss.
    c. Limit range-of-motion exercises.
    d. Help to maintain functional position.
    e. Advent of topical antibiotics has led to decreased use.
  • Exposure method.
    a. Allows for drainage of burn exudate.
    b. Eschar forms protective covering.
    c. Use of topical therapy.
    d. Skin easily inspected.
    e. Range-of-motion exercises easier to perform.

M. Apply topical preparations to wound area.

  • Sulfamylon (mafenide) 5% to 10%.
    a. Exerts bacteriostatic action against many organisms.
    b. Penetrates tissue wall.
    c. Dressings not needed when used.
    d. Agent of choice for electrical burns.
    e. Breakdown of drug provides heavy acid load. Inhibition of carbonic anhydrase compounds situation.
    f. Monitor arterial blood gases (ABGs) for acidosis. Individual compensates by hyperventilating.
    g. Alternate use with Silvadene (silver sulfadiazine).
    h. Topical of choice for electrical burns.
  • Silvadene 1%.
    a. Broad antimicrobial activity.
    b. Effective against yeast.
    c. Inhibits bacteria resistant to other antimicrobials.
    (1) Not usually used prophylactically.
    (2) Given for specific organism.
    (3) Not helpful first 48 hours due to vessel thrombosis.
    d. Can be washed off with water.
    e. Assess for leukopenia after 2–3 days—may resolve automatically.
  • Silver nitrate 0.5%.
    a. Used for many years but decreasing in popularity.
    b. Controls bacteria in wound and reduces water evaporation.
    c. Disadvantages are that it acts only on surface organisms, dressings are messy and must be kept wet, and bulk of dressing decreases ROM, electrolyte imbalance (low sodium, chloride, calcium, and potassium).

N. Administer systemic antibiotics when there is wound sepsis or positive cultures.
O. Debridement and eschar removal daily.
P. Provide long-term care.

  • Maintain good positioning to prevent contractures.
  • Prevent infection.
  • Maintain adequate protein and caloric intake to promote healing.
  • Monitor hydration status.
  • Protect skin grafts.
  • Provide psychological support (as important as physical care).
    a. Deal with the client’s fear of disfigurement and immobility from scarring.
    b. Provide constant support, as plastic repair is lengthy and painful.
    c. Involve the family in long-term planning and day-to-day care.

Q. Design activities for the burned child while child is hospitalized.

  • Actively involve the child (e.g., acting out part of a story verbally).
  • Provide television, books, and games.
  • Allow the child to associate with friends.

R. Counsel parents.

  • Parents and child have difficulty dealing with disfigurement and need assistance.
  • Parents frequently feel guilty, although they are usually not at fault and need assistance working out these feelings.

Isolation Protocol

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing
Medical–Surgical Nursing

Medical–Surgical Nursing: Lyme Disease

Focus topic: Medical–Surgical Nursing

Definition: A multisystem inflammatory disorder caused by an infection acquired through ticks that live in wooded areas and survive by attaching themselves to animal and human hosts.

Assessment
A. Disease is caused by a spirochete.
B. This disease has many and varied symptoms and is difficult to diagnose because it masquerades as other illnesses.
C. Following a tick bite, the first symptoms occur several days to a month following the bite.

  • Assess for a small red pimple, macule, or papule that spreads into a ringed-shaped rash in 4–20 days. Rash may be large or small, or not occur at all (making diagnosis difficult).
  • Assess for flulike symptoms: headache, stiff neck, muscle aches, and fatigue.

D. Assess for the second stage occurring several weeks following the bite: central nervous system abnormalities; heart disease symptoms—heart block or joint pain (arthritis).
E. Assess for third-stage symptoms: arthritis progresses and large joints are usually involved (50%).

  • Lingering Lyme arthritis may be caused by lingering infection or immune response.
  • A test called the polymerase chain reaction (PCR) identifies persistent Lyme arthritis that may persist even after aggressive antibiotic therapy.

Implementation
A. Blood test may detect the disease but is usually negative during the early phases.

  • Once diagnosis is confirmed, administer antibiotics— dosage depends on severity of symptoms.
  • Penicillin-type drugs given as soon as possible— shorten course of disease.
  • IV Rocephin (ceftriaxone) is prescribed for severe cardiac and neurologic problems.

B. Prevention is the best treatment.

  • Avoid areas that contain ticks—those that are wooded, grassy, especially in the summer months. There is no vaccine.
  • Wear tight-fitting clothing and spray body with tick repellent.
  • Examine entire body for ticks upon return home; if tick is located, remove with tweezers and wash skin with antiseptic, and preserve tick for examination.

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