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Chapter 1 Medical Surgical Nursing

Medical-surgical nursing- health promotion, health care, and illness care of adults based on knowledge derived from
the arts and science and shaped by knowledge (the science) of nursing.

Focuses on adult clients response to actual or potential alterations in health


Client- based on a philosophy that individuals are active participants in health and illness as well as consumers of
healthcare services
National Academy of Sciences proposed a set of five core competencies that all healthcare professionals should
possess, regardless of their discipline. They are based on using communications, knowledge, technical skills, critical
thinking, and values in clinical practice. (Table 1-1; pg 5)

Provide client-centered care

Work in interdisciplinary teams

Use evidence based practice

Apply quality improvement

Use informatics
Critical thinking- thinking about ones own thinking. It is self-directed that is focused on what to believe or do in a
specific situation. Consider:

Purpose of thinking

Your level of acquired knowledge

Prejudices that may influence thinking

Information that is needed from other sources

Ability to identify other options

Personal values and beliefs


Critical thinking skills

Divergent thinking- having the ability to weigh the importance of information (abnormal data are
usually considered relevant, normal data are helpful but may not change the care you provide)

Reasoning- having the ability to discriminate between facts and guesses

Clarifying- noting similarities and differences to sift out unnecessary information to help focus on the
present situation

Reflection- comparing different situations with similar solutions


The nursing process benefits nurses who provide care, clients who receive care, and setting where care is provided.
The five steps or phases in the nursing process are assessment, diagnoses, planning, implementation, and evaluation.
(Table 1-2; pg 7)
Outcomes of planning should be mutually established by the client and the nurse. Outcome criteria are client
centered, time specific, and measurable; they are classified into three domains which are cognitive (knowing),
affective (feeling), and psychomotor (doing).
Code of Ethics one criterion that defines a profession (Box 1-2; pg 11)
Ethics- principles of conduct concerned with moral duty, values, obligations, and the distinction between right and
wrong.
Standard- statement or criterion that can be used by a profession and by the general public to measure quality of
practice (Box 1-3; pg 11)
Dilemma- choice between two unpleasant, ethically troubling alternative
Advance directive- living will, a document in which a client formally states preferences for health care in the event
that he or she later becomes mentally incapacitated
Culturally sensitive nursing (Box 1-4)
Roles of the nurse in medical surgical nursing practice

Caregiver

Leader and manager

Educator

Researcher

Advocate
Case management- focuses on management of a caseload (groups) of clients and the members of the healthcare team
caring for those clients. The purpose is to maximize positive outcome and contain costs

Delegation- carried out when the nurse assigns appropriate and effective work activities to other members of the
healthcare team; the nurse retains the accountability for the activities performed by other nurses.
Critical pathway- healthcare plan designed to provide care with a multidisciplinary interventions, including education,
discharge planning, consultations, medication administration, diagnosis, therapeutics, and treatments
Quality assurance- consists of the quality control activities that evaluate, monitor, or regulate the standard of services
provided to the consumer
Chapter 2 (Blue Book)
Health and Illness in the Adult Client
Health- as a state of complete physical, mental, and social well being and not merely the absence of disease or
infirmity.
The Health-illness continuum represents health as a dynamic process, with high level wellness at one extreme of the
continuum and death at the opposite extreme. (Look at figure 2-1)
Holistic health care- is when all aspects of a person (physical, psychosocial, cultural, spiritual, and intellectual) are
considered as essential components of individualized care.
Factors affecting Health
Genetic Makeup- affects personality, temperament, body structure, intellectual potential, and susceptibility to the
development of hereditary alterations in health.
Cognitive Abilities and Educational Level- although cognitive abilities are determined prior to adulthood, the
level of cognitive development affects whether people view themselves as healthy or ill; cognitive levels also may
affect health practices.
Race, Ethnicity, and Cultural Background- Certain diseases occur at a higher rate of incidence in some races and
ethnic groups than in others. The ethnic and cultural background of an individual also influences health values and
behaviors, lifestyle and illness behaviors.
o Ex. Hypertension is more prevalent among African Americans, TB and diabetes is more common among
Native Americans, eye problems among Chinese Americans.
Age, Gender, and Developmental Level
Lifestyle and Environment- The components of a persons lifestyle that affect health status include patterns of
eating, use of chemical substances (alcohol, nicotine, caffeine, legal and illegal drugs), exercise and rest patterns
and coping methods.
Socioeconomic Background-Both lifestyle & environment influences are affected by ones income level. The
culture of poverty, which crosses all racial & ethnic boundaries, negatively influences health status.
Geographic Area- the geographic area in which one lives influences health status.
Health Promotion and Maintenance (Box 2-1)
Eat three balanced meals a day
Eliminate smoking
Exercise moderately and regularly
Keep sun exposure to a minimum.
Sleep 7 to 8 hours each day
Maintain recommended immunizations (Table 2-1)
Limit alcohol consumption to a moderate
amount and favor red wine.
Disease and Illness
Disease and Illness are terms that are often used interchangeably, but in fact they have different meanings.
Disease- a medical term describing alterations in structure and function of the body or mind. Diseases may have
mechanical, geologic, are normative causes.
o Mechanical causes of disease result in damage to the structure of the body and are the result of trauma or
extremes of temperature.
o Biologic causes of disease affect body function and are the result of genetic defects, the effects of aging,
infestation & infection, alterations in the immune system, & alterations in normal organ secretions.
o Normative causes are psychologic but involve a mind body interaction, so that physical manifestations occur
in response to the psychologic disturbance.
Acute- a disease that has a rapid onset, lasts a relatively short time, and is self limiting
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Chronic- a disease that is has one or more of these characteristics: 1) Is permanent 2) leaves permanent disability
3) causes nonreversible pathophysiology 4) requires special training of the client for rehabilitation, 5) requires a
long period of care; usually characterized by periods of remission and exacerbation.
Remission- the person does not experience symptoms even though the disease is clinically present.
Exacerbation- the symptoms reappear
Communicable- a disease that can spread form one person to another
Congenital- a disease or disorder that exists at or before birth
Degenerative- a disease that results from deterioration or impairment of organs or tissues
Functional- a disease that affects fxn or performance but does not have manifestations of organic illness
Malignant- a disease that tends to become worse and cause death
Psychosomatic- a psychologic disease that is manifested by physiologic symptoms
Idiopathic- a disease that has an unknown cause
Iatrogenic- a disease that is caused by medical therapy
Illness- is the response a person has to a disease; response is highly individualized
Illness behaviors- the way people cope with the alterations in health and function caused by disease; are highly
individualized and are influenced by age, gender, family values, economic status, culture, educational level, and
mental status.
A sequence of Illness behaviors :
Experiencing symptoms- The most significant manifestations is pain.
Assuming the sick role- The person usually validates this belief with others and seeks support for the need to
have professional treatment or to stay at home form school or work.
Seeking medical care- People who believe themselves to be ill and who are encouraged by others to contact
a healthcare provider
Assuming a dependent role- this begins when a person accepts the diagnosis and planned treatment of the
illness. It is in this stage that the person may enter the hospital for treatment and care.
Achieving recovery and rehabilitation- the person now gives up the dependent role and resumes normal
roles and responsibilities. As a result of education during treatment and care, the person may be at a higher
level of wellness after recovery is complete.
The response of the person to the illness is influenced by the following factors:
The point in the life cycle at which the onset of the illness occurs
The type and degree of limitations imposed by the illness
The visibility of impairment or disfigurement
The pathophysiology causing the illness
The relationship between the impairment and functioning in social roles
Pain and fear
Things to do if the patient has a chronic illness.
Live normally as possible
Learn to adapt activities of daily living and self care activities
Grieve the loss of physical function and structure, income, status, roles, and dignity
Comply with a medical treatment plan
Maintain a positive self-concept and a sense of hope.
Maintain a feeling of being in control
Confront the inevitability of death.
Illness Prevention
Primary Prevention- includes generalized health promotion activities as well as specific actions that prevent or
delay the occurrence of a disease.
o Ex: Protecting oneself against environmental risks, such as air and water pollution, eating nutritious foods,
sunscreen, seat belts, practicing safe sex, immunizations.
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Secondary Prevention-involves early diagnosis and treatment of an illness that is already present, to stop the
pathologic process and enable the person to return to their former state of health as soon as possible.
o Ex: Having screenings for diseases such as hypertension, diabetes mellitus, and glaucoma, obtaining physical
exams and diagnostic tests for cancer, performing self examination for breast or testicular cancer, TB skin
tests
Tertiary Prevention- This level focuses on stopping the disease process and returning the affected individual to a
useful place in society within the constraints of any disability.
o Ex: Obtaining medical or surgical treatment for an illness, enrolling in specific rehab programs, joining work
training programs following illness or injury
Meeting health needs of adults (tables 2-4, 2-5, 2-6, and 2-7 and boxes 2-3, 2-4, 2-5).
The adult years are divided into three stages: the young adult (ages 18 to 40), the middle adult (ages 40 to
65) and the older adult (over 65).
The young adult 18 to 25, the healthy young adult is at the peak of physical development.
Risks for alterations in Health
The young adult is at risk for alterations in health form accidents sexually transmitted diseases, substance
abuse, and physical or psychosocial stressors.
The middle adult is at risk for alterations in health from obesity, cardiovascular disease, cancer, substance
abuse, physical stressors.
The older adult has problems with hypertension, arthritis, heart diseases, cancer, sinusitis, pharmacologic
effects, physical and psychosocial stressors and diabetes. The risks for injury in older adults are also at risk
for falls, fires, and motor vehicle crashes.
Chapter 4- Blue Book- The Surgical Client
Surgery- an invasive medical procedure performed to diagnose or treat illness, injury, or deformity.
Invasive- any procedure that goes inside the body cavity, breaks the skin; ex surgery, catheter, etc
Perioperative period- the total surgical episode
Preoperative period- begins when the decision for surgery is made and ends when the client is transferred to the
operating room
Intraoperative period- begins when the client enters the operating room and ends with admitted to the
postanesthesia care unit(PACU), or recovery room
Postoperative period- begins with the clients admitted to the PACU and ends with the clients complete recovery
from the surgical intervention
Ambulatory Surgery- have surgery and leave in the same day
Classification of Surgical Procedures:
Purpose:
o Diagnostic- determine or confirm a diagnosis; breast biopsy, bronchoscope
o Ablative- remove diseased tissue, organ, or extremity; appendectomy, amputation
o Constructive- build tissue/organs that are absent; repair of cleft palate
o Reconstructive- rebuild tissue/organ that has been damaged; skin graft after a burn, total joint replacement
o Palliative- alleviate symptoms of a disease(not curative); bowel resection in client with terminal cancer
o Transplant- replace organs/tissue to restore function; heart, lung, liver, kidney transplant
o Cosmetic- face lift, breast augmentation
Risk Factor:
o Minor- minimal physical assault with minimal risk; removal of skin lesions, dilation and curettage, cataract
extraction
o Major- extensive physical assault and/or serious risk; transplant, total joint replacement, colostomy
Urgency:
o Elective- suggested, though no foreseen ill effects if postponed; cosmetic surgery
o Urgent- necessary to be performed within 1 to 2 days; heart bypass, amputation b/c of gangrene, fractured hip
o Emergency- performed immediately; obstetric emergencies, bowel obstructions; life threatening trauma
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Assessments before Surgery:


Age, nutrition, obesity, immunocompetence, fluid and electrolyte imbalances, pregnancy
Previous surgeries
Client misperceptions
Medication history
Allergies
Smoking habits, alcohol, substance abuse- reacts with anesthesia
Family support- for rehab
Occupation- may have to take off work to recover
Preoperative pain- document how much pain in before and then after
Emotional health
Culture- very important b/c ppl view pain differently
Client expectations

Physical Assessment:
General survey
Heart and vascular system
Head and neck
Abdomen
Integument
Neurological status
Thorax and lungs
Diagnostic tests- provide baseline data or reveal problems that may place the client at additional risk during and after
surgery
Trend of shorter hospital stays = studies and procedures are performed in a preadmission clinic within a week
prior to elective surgery
Most commonly performed preoperative lab tests- Complete blood counts, electrolyte studies, coagulation
studies, and urinalysis
Hemoglobin and Hematocrito Increased- dehydration, excessive fluid plasma loss, polycythemia vera
o Decreased- fluid overload, excessive blood loss, anemia
o Nursing implications- monitor oxygenation, I&O, vital signs, assess for bleeding
WBC counto Increased- infectious/inflammatory processes, leukemia
o Decreased- inadequate glucose intake in relation to insulin
o Nursing Implications- inflammation, temp, pulse
Electrolytes- KNOW VALUES!
Look at pg 943 in KOZIER TEXT!!! (also look in blue book)
X-rays- older clients with risk factors related to heart and lung function; provides baseline info about the size,
shape, and condition of the heart and lungs
ECG- electrocardiogram; ordered for clients undergoing general anesthesia when they are 40 years of age or have
cardiovascular disease
Creatine clearance- best indicator of renal function
CBC- see if it is ok to lose any amount of blood
Serum electrolytes and creatine- know normal ranges
Coagulation studies- see if patient clots normally
BUN levels
Glucose, UA, HCG-human chorionic gonadotropin
Look at Nursing Diagnoses on pg 70 in blue book!
Client teaching- the most important part of postoperative phase
Client expectations, what they will experience- nurse needs to listen to client and identify concerns and fears
Psychosocial support to reduce anxiety
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Tell the client the roles of each person involved- client and family during each phase of procedure
Skills training- moving, deep breathing, coughing, splinting, or incentive spirometer
Box 37-4 pg 945 Kozier text!
Informed Consent- disclosure of risks associated with the intended procedure or operation to the client, and includes a
legal document required for certain procedures and surgeries
Need for the procedure in relation to the diagnoses
Description and purpose of the proposed procedure
Possible benefits and potential risks
Likelihood of a successful outcome
Alternative treatments or procedures available
Anticipated risks
Physicians advice as to what is needed
Right to refuse treatment or withdraw consent
o The nurse can discuss this information with the client
o If the client has concerns , the surgeon is responsible for supplying further information
Perioperative Risk Factors
1) Verifying the procedure
2) Physically marking and initializing the site
3) Taking a Time Out before starting any procedure- To ensure the right procedure will be performed on the
right client on the correct site with the necessary and correct healthcare providers there- This is all done BEFORE
the patient is anesthetized
A complete medication history- OTC, RX, and herbals
Anticoagulation medications should be discontinued before surgery- prevent excessive blood loss during surgery
Hyperthermia and hypothermia are risks
o Warm blankets
o Limit amount of exposed skin
o Prevent surgical drapes from becoming wet
o Adjust room temp to normal
o Monitor clients temp and avoid over heat
o Use heat maintenance devices
o Warm irrigation or infusion solutions
o Humidify airway
*In Diabetic clients, the stress of surgery increases blood sugar*
Immediate Care: PACU
Care begins when client has been transferred from operating room to the PACU.
PACU nurse monitors VS and surgical site to determine response to procedure and detect significant changes.
They also assess mental status and orient X3, evaluate Input and Output, and pain level
PACU nurses also offer emotional support which is essential b/c client is vulnerable
Inform the floor nurse about client's condition and any post-op orders prior to client arrival back to their room.
Post-OP head to toe assessment includes:
o General appearance
o VS
o N/V
o LOC
o type of IV fluids and flow
o Emotional status
o Dressing site
o Quality of respirations
o Drainage on dressing or bed
o Skin Color & Temp
o Urinary output
o Pain level
o Ability to move all extremities
After major surgery the nurse generally asses client every 15 min during first hour & once stable every 30 for
about 2 hours and then every 4 hours
Ensure clients safety
Cardiovascular Post-OP Complications
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SHOCK
-life threatening b/c of insufficient blood flow to vital organs, inability to use oxygen and
nutrients, inability to rid waste
o Hypovolemic shock is most common and results from decrease in circulating fluid volume from blood or
plasma loss

hemorrhage
o excessive blood loss
o a concealed is internally from blood vessel thats not sutured/cauterized or drainage tube that has eroded the
vessel
o Obvious hemorrhage is externally from a dislodged or ill-formed clot at the wound.
o hemorrhage may occur b/c of abnormalities in blood's clotting
o hemorrhage from a vein oozes quickly & is dark red, arteries its bright red spurts of blood pulsating w/ each
beat
o Nursing Care for hemorrhage is
stopping the bleeding,
replenishing blood volume,
care for shock and apply pressure with either gloved hand or applying one or more sterile gauze pads
Prepare the client and family for emergency surgery all depending on the severity.
Deep vein thrombosis
o blood clot associated with inflammation in deep veins; usually occurs in lower extremities
o may result from trauma during surgery, pressure under knee, or sluggish blood flow during and after surgery
o clients most at risk are over 40 and:
have had orthopedic surgery to lower extremities; urologic, gynecologic, or OB surgeries, or neurosurgery
have varicose veins
history of thrombophlebitis or pulmonary emboli
are obese
have an infection
have a malignancy
o common assessment findings
pain or cramping in calf or thigh
redness edema of entire extremity with slightly elevated temp
may have positive Homan's sign (pain in calf on dorsiflexion of the affected foot)
o Nursing care for DVT
focuses on preventing a portion of clot from dislodging and becoming an embolus to heart, brain, or lungs
preventing other clots from forming
supporting the client's own physiologic mechanism for dissolving clots
Admin anticoagulants as prescribed (NSAIDs not usually given with these b/c it increase affect)
monitor lab values for clotting time
maintain bed rest and keep affect extremity at or below heart
apply thigh-high antiemboli stocking or device
ensure affected area is not rubbed or massaged
apply heat as prescribed
Record bilateral calf or thigh circumference and asses color and temp every shift.
Pulmonary embolism
o A dislodged blood clot or other substances that lodges in a pulmonary artery.
o common assessment findings in client with pulmonary embolism include:
mild to moderate dyspnea
rapid respirations and pulse
chest pain
dysrhymias
diaphoresis
cough
anxiety
cyanosis
restlessness

Nursing care for embolis


Stabilize respiratory and cardiovascular functioning while preventing formation of additional emboli is
most imp.
Notify physician
frequently assess and record general condition and VS
maintain client on bed rest and keep head of bed elevated
provide oxygen as ordered and monitor pulse oximetry
admin prescribed IV fluids to maintain balance while preventing fluid overload
maintain comfort by administering analgesics and sedatives
Respiratory Post-OP Complications
Pneumonia
o Inflammation of lung tissue caused by either microbial infection or foreign sub. In lung that causes infection.
o Factors that may be involved in development
aspiration infection
retained pulmonary secretions
failure to cough deeply
impaired cough reflex
decreased motility
o Common assessment findings of post-op client with pneumonia
high fever
rapid pulse and respirations
chills (may be present initially)
productive cough (may be present depending on the type of pneumonia)
dyspnea
chest pain
crackles & wheezes
o Goals in nursing care
treat the infection
support respiratory effects
promote lung expansion
preventing organisms spread
o Nursing care for pneumonia
obtain sputum specimen for C & S testing
position client with head of bed up
encourage the client to turn, cough, and perform deep breathing exercises at least every 2 hours
assist with incentive spirometry, intermittent positive pressure breathing and/or nebulizer treatment
ambulate client as condition permits
admin oxygen as ordered
asses VS, breath sounds, and general condition
Maintain hydration to help liquefy pulmonary secretions
administer antibiotics, expectorants, antipyretics, and analgesic
provide or assist with frequent oral hygiene
prevent spread of microorganism by teaching proper disposal of tissues, cover mouth when coughing, and
good hand washing
Atelectasis
o incomplete expansion/collapse of lung tissue resulting in inadequate ventilation & retention of pulmonary
secretions
o
o Common Assessment findings:
dyspnea
diminished breath sounds over affected area
anxiety and restlessness
o

crackles
cyanosis
o Nursing Care for atelectasis:
position head of bed up
admin oxygen as prescribed
encourage coughing, turning, and deep breathing every 2 hours
ambulate the client as condition permits
Assist with incentive spirometry or other pulmonary exercises such as inflating a balloon, as ordered.
promote hydration
Wound Post-OP Complications
Common assessment findings of infected wounds:
o pain
o purulent odorous discharge
o redness
o warmth
o tenderness
o edema around the edges of incision
o fever
o chills
o increased respiratory and pulse rates
Nursing Care for wounds:
o prevent and monitor for complications
o support healing process, provide emotional support, teach wound care
o maintain medical asepsis
o follow CDC guidelines for wound care
o Observe aseptic technique during dressing change and handling of drains and tubes
o asses VS, especially temp
o evaluate characteristics of wound discharge (COCA)
o asses condition of incision (approximation of edges, sutures, staples, or drains)
o Clean, irrigate, and pack wound in prescribed manner. Sterile NS is often prescribed iodine is not
recommended
o maintain hydration and nutritional status
o culture wound prior to beginning antibiotics
Dehiscence- separation in layers of incise
onal wound- cover wound with sterile dressing moistened with NS immediately
Evisceration- protrusion of body organs from a wound dehiscence
Wounds
Primary intention healing
o When the wound is uncomplicated and clean and has sustained little tissue loss.
o The edges are well approximated (come together well) with sutures, staples or superglue.
o heal quickly and have very little scarring
Secondary intention healing
o When wound is large, gapping, and irregular.
o tissue loss prevents wound edges from approximating
o granulation tissue fills the wound
o takes longer to heal, more prone to infection, and develops more scar tissue
Tertiary intention healing
o when enough time passes before a wound is sutured
o infection likely to take place
o wound edges are not approximated
o tissue is regenerated by granulation process
o closure results in big scar
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stages of wound healing


o All wounds heal in four stages
o Healing time varies according to age, nutritional status, general health, and type and location of wound
Stage 1 (from surgery thru day 2)
Stage 2 (day 3 thru day 14)
Stage 3 ( day 15 thru week 6)
Stage 4 (several months to a year following surgery)
**Look on pg 76 for complete description if needed
Post-OP Complications associated with Elimination
Urinary retention
o may occur as result of
recumbent position,
effects of anesthesia or narcotics,
inactivity, altered fluid balance, nervous tension,
surgical manipulation in pelvic area
o Nursing Care for urinary retention:
promote normal urinary elimination
asses for bladder distention
asses amount of urine in bladder with portable ultrasound scanner(non-invasive to see if catheter is
needed)
monitor input and output
Maintain IV infusion if prescribed
Increase daily oral fluid intake to 2500-3000 ml if condition permits
insert straight or indwelling catheter if ordered
Promote normal urinary elimination by:
-assisting & providing privacy with bedpan
-help to BSC
-assist male to stand to void
-pour a measured amt of warm water over perineal area (if they pee, subtract amt of water from total amt)
Bowel elimination
o may occur as result of
general anesthesia
narcotic analgesia
decreased motility
altered fluid and food intake during pre-op period
o Nursing Care for normal bowel function
Asses for return of normal peristalsis
auscultate bowel sounds every 4 hours while client is wake
asses abdomen for distention
determine if client is passing flatus
monitor for passage of stool, including amount and consistency
encourage early ambulation within prescribed limits
facilitate a daily fluid intake of 2500-3000 ml (unless contraindicated)
provide privacy
if no BM has occurred within 3-4 days after surgery a supp or enema may be ordered
**Special Considerations for older adults Pg 79 chart
Chapter 35 (old book)
medication- a substance administered for the diagnosis, cure, treatment, or relief of a symptom or for prevention of
disease; used interchangeably with the word drug
drug- also has the connotation of an illicitly obtained substance such as heroin, cocaine, or amphetamines; crude
drugs: opium, caster oil, and vinegar (used in ancient days)
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prescription- written direction for the preparation and administration of a drug


generic name- given before a drug becomes officially an approved medication; used throughout the drugs use
official name- the name under which it is listed in one of the official publications (ex: United States Pharmacopeia)
chemical name- the name y which a chemist knows it; describes the constituents of the drug precisely
trade name- the name given by the drug by the drug manufacturer; the name usually selected to be short and easy to
remember; aka: brand name
pharmacology- the study of the effect of drugs on living organisms
pharmacy- the art of preparing, compounding, and dispensing drugs
pharmacist- prepares the drug; person licensed to prepare and dispense drug and to make up prescriptions
clinical pharmacist- specialist who often guides the physician in prescribing drugs
pharmacy technician- a member of the health team who in some states administer drugs to clients
Type of Drug Preparations
Aerosol spray or foam- a liquid, powder, or foam deposited in a thin layer on the skin by air pressure
Aqueous solution- one or more drugs dissolved in water
Aqueous suspension- one or more drugs finely divided in a liquid such as water
Caplet- a solid form, shaped like a capsule, coated and easily swallowed
Capsule- a gelatinous container to hold a drug in powder, liquid, or oil form
Cream- a nongreasy, semisolid preparation used on the skin
Elixir- a sweetened and aromatic solution of alcohol used as a vehicle for medicinal agents
Extract- a concentrated form of a drug made from vegetables or animals
Gel or jelly- a clear or translucent semisolid that liquefies when applied to the skin
Liniment- a medication mixed with alcohol, oil, or soapy emollient and applied to the skin
Lotion- a medication in a liquid suspension applied to the skin
Lozenge (troche)- a flat, round, or oval preparation that dissolves and releases a drug when held in the mouth
Ointment (salve, unction)- a semisolid preparation of one or more drugs used for application to the skin and
mucous membrane
Paste- a preparation like an ointment, but thicker and stiff, that penetrates the skin less than an ointment
Pill- one or more drugs , mixed with a cohesive material, in oval, round, or flattened shapes
Powder- a finely ground drug or drugs; some are used internally, other externally
Suppository- one or several drugs mixed with a firm base such as gelatin and shaped for insertion into the body
(ex: the rectum); the base dissolves gradually at body temperature, releasing the drug
Syrup- aqueous solution
Tablet- a powdered drug compressed into a hard small disc; some are readily broken along a scored line; others
are enteric coated to prevent them from dissolving in the stomach
Tincture- an alcoholic or water-and-alcohol solution prepared from drugs derived from plants
Transdermal patch- a semipermeable membrane shaped in the form of a disc or patch that contains a drug to be
absorbed through the skin over a long period of time
Drugs may have natural (plant, mineral, and animal) sources, or they may be synthesized in the laboratory
Digitalis and opium are plant derived
Iron and sodium chloride are minerals
Insulin and vaccines have animal or human sources
Drugs vary in strength and activity
Official drugs are those designated by the federal Food, Drug, and Cosmetic Act
United States Pharmacopeia (USP) describe drugs according to their source, physical and chemical properties, tests
for purity and identity, method of storage, assay, category, and normal dosages
The natural form varies in strength and is difficult to regulate
Pharmacopeia- is a book containing a list of products used in medicine, with descriptions of the product, chemical
tests for determining identity and purity, and formulas and prescriptions
The United States National Formulary lists drugs and their therapeutic value and can include drugs that may still be
used but not listed in the USP.
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Pharmacopoeias and formularies are invaluable reference sources for nurses and nursing students
Legal Aspects of Drug Administration
Nurses need to know how nursing practice acts in their areas define and limit their functions and be able to
recognize the limits of their own knowledge and skill
A nurse who administers the written incorrect dosage is responsible for the error as sell as the physician
The information required (for special inventory forms) usually includes the name of the client, the date and time
of administration, the name of the drug, the dosage, an d the signature of the person who prepared and gave the
drug
Some agencies may require a verifying signature of another registered nurse for administration of a controlled
substance
Food, Drug, and Cosmetic Act- implemented by Food and Drug Administration (FDA); requires that labels be
accurate and that all drugs be tested for harmful effects
Effects of Drugs (table 35-4 and table 35-5 pg. 833)
Therapeutic effects (desired effect)- the primary effect intended, that is, the reason the drug is prescribed
Side effect- secondary effect, of a drug is one that is unintended; usually predictable and may be either harmless
or potentially harmful; some are tolerated for the drugs therapeutic effects
Adverse effects- more severe side effects; reactions, may justify the discontinuation of a drug
Drug toxicity- (deleterious effects of a drug on an organism or tissue) results from overdosage, ingestion of a
drug intended for external use, and buildup of the drug in the blood because of impaired metabolism or excretion
(cumulative effect)
Drug allergy- an immunologic reaction to a drug
Allergic reactions can be either mild or severe. A mild reaction has a variety of symptoms, form skin rashes to
diarrhea
Anaphylactic reaction- a severe allergic reaction usually occurs immediately after the administration of the drug;
the response can be fatal if the symptoms are not noticed immediately and treatment is not obtained promptly;
early symptoms are a subjective feeling of swelling in the mouth and tongue, acute shortness of breath, acute
hypotension, and tachycardia
Drug tolerance- exists in a person who has unusually low physiologic response to a drug and who requires
increase in the dosage to maintain a given therapeutic effect; drugs that commonly produce tolerance are opiates,
barbiturates, ethyl alcohol, and tobacco
Cumulative effect- is the increasing response to repeated doses of a drug that occurs when the rate of
administration exceeds the rate of metabolism or excretion
Idiosyncratic effects- one that is unexpected and may be individual to a client; underresponse and overresponse;
drug may have a completely different effect from the normal one or cause unpredictable and unexplainable
symptoms in a particular client
Drug interaction- occurs when the administration of one drug before, at the same time as, or after another drug
alters the effect of one or both drugs; may be beneficial or harmful
o Potentiating effect- effect of one or both drugs may increase; may be additive or synergistic
Additive- when two of the same types of drugs increase the action of each other
Synergistic- when two different drugs increase the action of one or another drug
o Inhibiting effect- effect of one or both drugs may decrease
Iatrogenic disease- (disease caused unintentionally by medical therapy) can be due to drug therapy; ex: hepatic
toxicity resulting in biliary obstruction, renal damage, and malformations of the fetus as a result of specific drugs
taken during pregnancy are examples
Drug Misuse
Drug misuse- the improper use of common medications in ways that lead to acute and chronic toxicity
Drug abuse- inappropriate intake of a substance, either continually or periodically; drug use is abusive when
society considers in abusive; two main facets:

12

drug dependence- a persons reliance on or need to take a drug substance; the two types of dependence,
physiologic and psychologic, may occur separately or together; a dependent person who stops using the drug
experiences withdrawal symptoms
physiologic dependence- due to biochemical changes in body tissues, especially the nervous system; these
tissues come to require the substance for normal functioning
psychologic dependence- emotional reliance on a drug to maintain a sense of well-being accompanied by
feelings of need or cravings for that drug; varying degrees ranging from mild desire to craving and
compulsive use of the drug
o drug habituation- denotes a mild form of psychologic dependence; the individual develops the habit of taking
the substance and feels better after taking it; habituated individual tends to continue that habit even though it
may be injurious to health
illicit drugs (street drugs)- those sold illegally; two types: drugs unavailable for purchase and drugs normally
available with a prescription that are being obtained through illegal channels; are often taken because of their
mood-altering effect (happy or relaxed)
Actions of Drugs on the Body
Actions can be described in terms of its half-life, the time intervals required for the bodys elimination processes
to reduce the concentration of the drug in the body by one-half
Because the purpose of most drug therapy is to maintain a constant drug level in the
Onset of action- the time after administration when the body initially responds to the drug
Peak plasma level- the highest plasma level achieved by a single dose when the elimination rate of a drug equals
the absorption rate
Drug half-half life (elimination half-life)- the time required for the elimination process to reduce the
concentration of the drug to one-half what it was at initial administration
Plateau- a maintained concentration of a drug in the plasma during a series of scheduled doses
Pharmacodynamics
Pharmacodynamics- the process by which a drug changes the body (alters cell physiology)
Receptor- usually a protein, is located on eh surface of a cell membrane or within the cell
Cell membranes contains receptors for physiologic or endogenous substances such as hormones and
neurotransmitters
Most drugs exert their effects by chemically binding with receptors at the cellular level
Agonist- a drug that produces the same type of response as the physiologic or endogenous substance
Antagonist- a drug that inhibits cell function by occupying receptor sites; prevents natural body substances or
other drugs from activating the functions of the cell by occupying the receptor sites
Pharmacokinetics
Pharmacokinetics- the study of the absorption, distribution, biotransformation, and excretion of drugs
Absorption- the process by which a drug passes into the bloodstream; the first step in the movement of the drug
through the body
o first-pass effect- when oral drugs first pass through the liver and are partially metabolized prior to reaching
the target organ; requires higher oral doses in order to achieve the appropriate effect
o intravenous route is the route of choice for rapid action
o intramuscular route is the next most rabid route due to the highly vascular nature for muscle tissue
o subcutaneous route is the slower because it has a poor blood supply
o the rate of absorption of a drug can be accelerated by the application of heat, which increases blood flow to
the area; conversely, absorption can be slowed by the application of cold
o some drugs intended to be absorbed slowly are suspended in a low-solubility medium, such as oil
o this route is normally used when other routes are unavailable or when the intended action is localized to the
rectum or sigmoid colon
Distribution- the transportation of a drug from its site of absorption to its site of action
o When a drug enters the bold stream, it is carried to the most vascular organs (liver, kidneys, and brain)
o Body areas with lower blood supply (skin and muscle) receive that drug later
o

13

o Fat-soluble drugs will accumulate in fatty tissue, whereas other drugs may bind with plasma proteins
Biotransformation (detoxification or metabolism)- is a process by which a drug is converted to a less active
form; makes place in the liver, where many drug-metabolizing enzymes in the cells detoxify the drugs (product is
called metabolites)
Two types of metabolites: active- has a pharmacologic action itself; inactive- does not have pharmacologic action
Excretion- the process by which metabolites and drugs are eliminated from the body
o Most metabolites are eliminated by the kidneys in the urine; however, some are excreted in the feces, the
breath, perspiration, saliva, and breast milk
o The efficiency with which the kidneys excrete drugs and metabolites diminishes with age. Older people may
require smaller doses of a drug because the drug and its metabolites may accumulate in the body
Developmental Factors Affecting Medication Actions
Drugs taken during pregnancy pose a risk throughout the pregnancy, but pose the highest risk during the 1 st
trimester, due to the formation of vital organs and functions of the fetus during this time.
Changes to response of meds include: decreased liver and kidney function (result in the accumulation of drugs in
the body)
Older people may be on multiple drugs and incompatibilities may occur
Older adults often experience decreased gastric motility and decreased gastric acid production and blood flow,
which can impair drug absorption.
Increased adipose tissue and decreased total body fluid proportionate to the body mass can increase the possibility
of drug toxicity
Older adults may also experience a decreased number of protein-binding sites and changes in the blood-brain
barrier, allowing fat-soluble drugs to move readily to the brain causing dizziness and confusion (esp. when taking
beta blockers)
Gender Factors Affecting Medication Actions
Differences in the way men and women respond to drugs are chiefly related to the distribution of body fat and
fluid and hormonal differences.
Cultural, Ethnic, and Genetic Factors Affecting Medication Actions
Pharmacogenetics- a clients response to a drug is influenced by genetic variations such as gender, size, and
body composition (vary by race or ethnic group)
Some clients may have slow liver metabolism and not achieve an adequate response to a medication, whereas
others are rapid metabolizers and may require lower doses of a medication to avoid adverse reactions
Ethnopharmacology- the study of the effect of ethnicity on responses to prescribed medication; incorporates
pharmacogenetics which is the study of the genetic ability to produce enzymes that affect drug metabolism
Diet Factors Affecting Medication Actions
Vitamin K found in green leafy vegetables can counteract the effect of an anticoagulant such as warfarin
Environmental Factors Affecting Medication Actions
Environmental temperature may affect drug activity.
When environmental temperature is high the peripheral blood vessels dilate, thus intensifying the action of
vasodilators.
A client who takes a sedative or analgesic in a busy, noisy environment may not benefit as fully as if the
environment were quiet and peaceful
Psychologic Factors Affecting Medication Actions
A clients expectations about what a drug can do can affect the response to the medication
Illness and Disease Affecting Medication Actions
Illness and disease can also affect the action of drugs
Drug action is altered in clients with circulatory, liver, or kidney dysfunction
Time of Administration Affecting Medication Actions
Orally administered medications are absorbed more quickly if the stomach is empty. Thus oral medications taken
2 hours before meals act faster than those taken those taken after meals.
Iron preparations, irritate the gastrointestinal tract and are given after a meal, when they will be better tolerated
14

Routes of Administration
Oral administration- most common route, least expensive, and most convenient route for most clients; drug is
swallowed
o major disadvantages are possibly unpleasant taste of the drugs, irritation of the gastric mucosa, irregular
absorption from the gastrointestinal tract, slow absorption, and, in some cases harm to the clients teeth
sublingual administration- drug is placed under the tongue where it dissolves; in a relatively short time, the drug
is largely absorbed into the blood vessels on the underside of the tongue; should not be swallowed (ex:
nitroglycerin)
buccal administration- pertaining to the cheek, a medication is held in the mouth against the mucous
membranes of the cheek until the drug dissolves; drug may act locally on the mucous membrane of the mouth or
systemically when it is swallowed in the saliva
parenteral administration- defined as other than through the alimentary or respiratory tract, by needle; common
types: subcutaneous (hypodermic), intramuscular, intradermal, and intravenous
o less common types: intra-atrial (artery), intracardiac (heart muscle), intraosseous (bone), intrathecal or
intraspinal (spinal canal), epidural (epidural space), and intra-articular (joint)
topical administration- those applied to a circumscribed surface area of the body; types:
o dermatologic preparations- applied to the skin
o instillations and irrigations- applied into body cavities or orifices, such as the urinary bladder, eyes, ears, nose,
rectum, or vagina
o inhalations- administered into the respiratory tract by a nebulizer or positive pressure breathing apparatus; air,
oxygen, and vapor are generally used to carry the drug into the lungs
Types of Medication Orders
Stat order- indicates that the medication is to be given immediately and only once
Single order (one-time order)- for medication to be given once at a specified time
Standing order- may or may not have a termination date; may be carried out indefinitely until an order is written
to cancel it, or it may be carried out for a specified number of days; in some agencies, standing orders are
automatically canceled after a specified number of days and must be reordered
PRN order (as needed)- permits the nurse to give a medication when, in the nurses judgment, the client requires
it; the nurse must use good judgment about when the medication is needed and when it can be safely administered
Essential Parts of a Drug Order (PRACTICE WRITING PRESCRIPTION pg. 842)
Clients full name
Date and time the order is written
Name of the drug to be administer
Dosage of the drug
Frequency of administration
Route of administration
signature of the person writing the order (an unsigned has no validity)
boxes 35-1 and box 35-2 pg. 841
Communicating a Medication Order
MARs (medication administration records) vary in form, but all include the clients name, room, and bed
number; drug name and dose; and times and method of administration
The nurse should always question the primary care provider about any order that is ambiguous, unusual, or
contraindicated by the clients condition
If the primary provider cannot be reached, document all attempts to contact the primary care provider and the
reason for withholding the meds.
Systems of Measurement and Calculations (REVIEW pgs. 844-845)
Administering Medications Safely (look at practice guidelines pg. 846)
The medication history includes information about the drugs the client is taking currently or has taken recently
An important part of the history is clients knowledge of their drug allergies
15

An illness occurring after a drug was taken may not be identified as an allergy, but the client may associate the
drug with an illness or unusual reaction
Also included in the history are the clients normal eating habits
It is also important for the nurse to identify any problems the client may have in self-administering a medication
Then nurse needs to consider socioeconomic factor for all client, but especially for elders. Two common problems
are lack of transportation to obtain medications and inadequate finances to purchase medications
Medication Reconciliation
Medication reconciliation- the process of creating the most accurate list possible of all medications a patient is
taking-including drug name, dosage, frequency, and route- and comparing drug that list against the physicians
admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all
transition points within the hospital
the nurse needs to make a complete list of the clients medication (including prescriptions, vitamins, supplements,
and over-the-counter) on admission
Medication Dispensing Systems

Medication cart
Medication cabinet

Medication room
Automated dispensing cabinet (ADC)

Process of Administering Medication (see box 35-3 pg. 850)


1. identify the client
2. inform the client
3. administer the drug
4. provide adjunctive intervention as indicated
5. record the drug administered
6. evaluate the clients response to the drug
Ten Rights of medication Administration (pg. 850 box 35-4)
o
o
o
o
o

right medication
right dose
right time
right route
right client

o
o
o
o
o

right client education


right documentation
right to refuse
right assessment
right evaluation

see box 35-35 pg. 851


Oral Medications (skill 35-1 pgs. 852-855)
as long as the client can swallow and retain the drug in the stomach, this is the route of choice
when clients are vomiting, has gastric or intestinal suction, or is unconscious and unable to swallow they are NPO
(nothing by mouth)
See lifespan considerations pgs. 855-856 and home care consideration pg. 856
Nasogastric and Gastrostomy Medication
Nasogastric and gastrostomy tubes- for clients who are NPO; an alternative route for administering medications
is through the NG or gastrostomy tube.
Parenteral Medication
Given ID, sub-q, IM, or IV
Equipment
o Syringes have three parts: tip (connects with the needle), barrel (outside, where scales are printed), and the
plunger (fits inside barrel)
the nurse must avoid letting any unsterile object tough the tip or inside of the barrel, the shaft of the
plunger, or the shaft or tip of the needle
hypodermic syringe- come in 2, 2.5, 3, and 5 mL sizes

16

insulin syringe- similar to hypodermic but the scale is specifically designed for insulin; calibrated in 100units
tuberculin syringe- originally designed to administer tuberculin solution, calibrated in tenths and
hundredths of a mL
syringes are made in other sizes like: 10, 20, and 50 mL
o Needles- three parts: hub (fits on syringe), cannula or shaft (attached to the hub), and bevel (slanted part of
the tip of the needle)
Three variable characteristics:
Slant or length of the bevel: longer bevels provide the sharpest needles & less discomfort
Length of the shaft: common length varies from to 2 inches; length is chosen according to the clients
muscle development, the clients weight, and the type of injection
Gauge- diameter of the shaft; varies from #18 to #28; larger the gauge the smaller the diameter
o Preventing needle sticks (pg. 860 box 35-6)
Preparing injectable medications
o Ampule- glass container usually designed to hold a single dose of a drug; vary in sizes from 1 to 10 mL or
more
o Vial- small glass bottle with a sealed rubber cap; come in different sizes, form single to multidose vials;
several vials are dispensed as powders in vials and a liquid must be added before it can be injected
(reconstitution)
o See skills 35-2 and 35-3 pgs. 862-864
o See skill 35-4 pgs. 865-866
Intradermal Injections- administration of a drug into the dermal layer of the skin just beneath the epidermis;
used for allergy testing and TB screening; common sights: inner lower arm, upper chest, and the back beneath the
scapulae (left arm for TB and right for all other) skill 35-5 pg. 867
Subcutaneous Injections- just beneath the skin; vaccines, insulin, and heparin; common sites: outer aspect of the
upper arms and anterior aspect of the thighs (both have good circulation), abdomen, scapular areas of upper back,
and upper ventrogluteal and dorsogluteal areas
o Only small doses 0.5 to 1 mL
o Needle sizes and lengths are selected based on the clients body mass, intended angle of insertion, and the
planned site; generally #25 gauge and 5/8 inch for 45-degree angle and 3/8 inch for 90 degree angle
o Pinch skin and determine length of needle (needle length is half the width of the skinfold)
o 45 angle for 1 inch of skin pinched and 90 angle for 2 inches of skin pinched
o Injection sites need to be rotated to minimize tissue damage, aid absorption, and avoid discomfort
o See skill 35-6 pgs. 870-872
Intramuscular injections- absorbed more quickly than sub-q injections because of the greater blood supply to
the body muscles
o Adult with well developed muscles can tolerate 3 mL of meds in the dorsogluteal and 1-2 mL with less
developed muscles
o Deltoid- 0.5-1 mL
o Standard needle is 1 inches and #21 or #22 gauge
o Indicates the size and length of the needle: the muscle, type of solution, amount of adipose tissue covering the
muscle, and the age of the client
o Viscous solutions require a larger gauge (#20 gauge)
o Obese pts. Require longer needle (2 in) and thin pts. need a shorter needle (1 in)
o Contraindications for using a specific site include tissue injury and the presence of nodules, lumps, abscesses,
tenderness, or other pathology
o Ventrogluteal site- preferred site b/c: contains no large nerves or blood vessels, provides the greatest thickness
of gluteal muscle, is sealed off by bone, and contains consistently less fat the buttock area; place in side-lying,
back, or prone positions.
o Vastus lateralis site- recommended for infants 1 year and younger; back lying or sitting position

17

o
o
o

Dorsogluteal site- dont give in children under 3 unless the child has been waking for at least 1 yr; make sure
you dont hit the sciatic nerve
Deltoid site- dont administer more than 1 mL, recommended for administration of the hep B vaccine in adult
Rectus femoris site- used occasionally for IM injections
Chapter 37 (old book)

Three phases of surgery:


Perioperative period- three phases together; the delivery of nursing care through the framework of the nursing
process; includes collaborating with members of the health care team, making nursing referrals, and delegating and
supervising
Preoperative phase- begins when the decision to have surgery is made and ends when the client is transferred to the
operating table
Nursing activities include: include assessing the client, identifying potential or actual health problems, planning
specific care based on the individuals needs, and providing preoperative teaching of the client the family, and
significant others
Intraoperative phase- begins when the client is transferred to the operating table and ends when the client is
admitted to the postanesthesia unit (PACU), or recovery room.
Create and maintain a safe therapeutic environment for the client and the health care professional
Clients safety, maintaining an aseptic environment, ensuring proper functioning of equipment, and providing the
surgical team with the instruments and supplies needed during the procedure
Postoperative phase- begins with the admission of the client to the postanesthesia area and ends when healing is
complete
Assessing the clients response to surgery, performing interventions to facilitate healing and prevent
complications, teaching and providing support people, and planning for home care
Outpatient procedures do not require an overnight hospital stay.
Surgical procedures are commonly grouped according to:
Purpose
o Diagnostic- confirms or establishes a diagnosis; for example, biopsy of a mass in a breast
o Palliative- relieves or reduces pain or symptoms of a disease, it does not cure; for example resection of nerve
roots
o Ablative- removes a diseased body part; for example, removal of the gallbladder (cholecystectomy)
o Constructive- restores function or appearance that has been lost or reduced; for example, breast implant
o Transplant- replaces malfunctioning structures; for examples kidney implant
Degree of urgency- classified by its urgency and necessity to preserve the clients life, body part, or body
function
o Emergency surgery- performed immediately to preserve function or the life of the client (repair a hemorrhage
or repair a fracture
o Elective surgery- performed when surgical intervention is the preferred treatment for a condition that is not
imminently life threatening or to improve the clients life
Degree of risk- is affective by the clients age, general health, nutritional status, use of medications, and mental
status
o Age- neonates, infants, and older adults are at greater risks than children and adults
the blood volume in an infant is small, and fluid reserves are limited which increases the risk of volume
depletion during surgery resulting in inadequate oxygenation of body tissues; because of an infants
relatively large body surface area and immature temperature regulatory mechanisms, the risk of
hypothermia during surgery is significant
because of a lower percentage of body water, decreased kidney function, and a decreased thirst response,
elders are at greater risk for fluid and electrolyte imbalances; the older adult may be poorly nourished
which can impair healing
o General health- any infection or pathophysiology increases the risk

18

Nutritional status- adequate nutrition is required for normal tissue repair; obesity contributes to postoperative
complications such as pneumonia, wound infections, and wound separation; a malnourished client is at risk
for delayed wound healing, wound infection, and fluid and electrolyte alterations
o Medications- anticoagulants (increase blood coagulation time), tranquilizers (may interact with anesthetics,
increasing the risk of respiratory infections), corticosteroids (may inference with wound healing and increase
the risk of infection). Diuretics (may affect fluid and electrolyte balance
o Major surgery- involves a high degree of risk, for a variety of reasons; it may be complicated or prolonged,
large losses of blood may occur, vital organs may be involved, or postoperative complications may be likely
(organ transplant, open heart surgery)
o Minor surgery- normally involves little risk, produces few complications, and is often performed in an
outpatient surgery (breast biopsy, knee surgery, removal of tonsils)
Preoperative consent- prior to any surgical procedure, informed consent is required from the client or legal guardian.
Informed consent implies that the client has been informed and involved in decisions affecting his or her health. The
surgeon is responsible for obtaining the informed consent by providing the information, and the nurse may witness the
signature. If the nurse assesses that the client does not understand the procedure to be performed, the surgeon is
contracted and requested to speak with the client before surgery can proceed
The surgical consent form, provided by the agency, protects the client from incorrect/unwanted procedures and the
surgeon and agency from litigation related to unauthorized surgeries or uniformed clients.
Preoperative assessment data (box 37-3) (table 37-2)*****(Box 37-4)
Preoperative teaching
Information, including what will happen to the client, when, and what the client will experience, such as expected
sensations and discomfort
Psychosocial support to reduce anxiety
The roles of the client and support people in preoperative preparation, the surgical procedure, and during the
postoperative phase
Skills training
Physical preparation
Adequate hydration and nutrition promote healing;; identify malnutrition and fluid imbalance
Enemas before surgery are no longer routine, but cleansing enemas may be ordered if bowel surgery is planned
Bath the night and morning before surgery
Remove hair pins and clips should be removed prior to surgery
All jewelry should be removed including body piercing because of risk of injury from burns if an electrosurgical
unit is used
Wedding ring should be taped in place by the nurse if they wish not to remove it.
All prostheses should be removes including artificial body parts, such as partial or complete dentures, contact
lenses, artificial eyes, and artificial limbs, eyeglasses, wigs, and false eyelashes, and hearing aids
Safety protocols- involves 3 steps
Step 1- preoperative verification at the time of surgery is scheduled, during admission, and whenever the client is
transferred to another caregiver
Step 2- marking of the operative site in an unambiguous manner; an X is considered ambiguous and cannot be
used to mark the site
Step 3- time-out final verification of the correct client, procedure, and site
General anesthesia- the loss of all sensation and consciousness; blocks awareness centers in the brain so that amnesia
(loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the
body less tense) occur
Regional anesthesia- temporary interruption of the transmission of nerve impulses to and from a specific area or
region of the body; the client loses sensation in an area of the body but remains conscious.
Topical (surface) anesthesia- applied directly to the skin and mucous membranes, open skin surface wounds, and
burns (Lidocaine, Xylocaine, and benzocaine)
Local anesthesia- infiltration; is injected into a specific area and is used for minor surgical procedures such as
suturing a small wound or performing
Nerve block- technique in which the anesthetic agent is injected into and around a nerve or small area of body
Intravenous block (Bier block)- used most often for procedures involving the arm, wrist, and hand
o

19

Spinal anesthesia (subarachnoid block SAB) - requires a lumbar puncture through one of the interspaces between
lumbar disc 2 (L2) and the sacrum (S1). An anesthetic agent is injected into the subarachnoid space surrounding
the spinal cord
Epidural (peridural) anesthesia- an injection of an anesthetic agent into the epidural space, the area inside the
spinal column but outside the dura mater
Conscious sedation- refers to minimal depression of the level of consciousness in which the client retains the ability
to maintain a patent airway and respond approximately to commands
Circulatory nurse- coordinates activities and manages client care by continually assessing client safety, aseptic
practice, and the environment
Scrub person- usually a UAP but can be a RN or LPN; their role is to assist the surgeon; they drape the client with
sterile drapes and handle sterile instruments and supplies
Surgical skin preparations
Clean the surgical site and surrounding area
Assess the surgical site before skin preparation
Remove hair from the surgical site only when necessary or according to the primary care providers orders or
institutional policies and procedures
Prepare the surgical site and surrounding area with antimicrobial agent when indicated
Document surgical skin preparation in the clients record
Review (Box 37-5)
In some agencies, assessments are made every 15 minutes until vital signs stabilize, every hour for the next 4 hours
for the next 2 days
Level of consciousness

Drains and tubes


Vital signs

Comfort
Skin color and temperature

Fluid balance
Dressing and bedclothes
Review (Table 37-3) Potential Postoperative Problems
Deep breathing exercises help exercises help remove mucus, which can form and remain in the lungs due to the
effects of general anesthetic and analgesics
Acelectasis- collapse of the alveoli
Encourage the client to do leg exercises taught in the preoperation period every 1 to 2 hours during waking hours
Muscle contractions compress the veins, preventing the stasis of blood in the veins, a cause of thrombus (stationary
cloth adhered to the wall of a vessel) formation and subsequent thrombophlebitis (inflammation of a vein followed by
formation of a blood clot) and emboli (a blood clot that has moved) Contractions also promote arterial blood flow
Encourage the client to turn from side to side at least every 2 hours; turning alternates which lung can achieve
maximum expansion because it is uppermost
Anesthetic agents temporarily depress urinary bladder tone, which usually returns within 6 to 8 hours after surgery
When dressing are changed, the nurse assesses the wound for appearance , size, drainage, swelling, pain, and the
status of drains and tubes

The nurse can expect the sequential signs of healing


Absence of bleeding and the appearance of a clot binding the wound edges
Inflammation (redness and swelling) at the wound edges 1 to 3 days
Reduction in inflammation when the clot diminishes
Scar formation
Diminished scar size over a period of months or years
Penrose drains, or surgical drains are inserted to permit the drainage of excessive serosanguineous fluid and purulent
material and to promote healing of underlying tissues
Closed-wound drainage system- consists of a drain connected to either an electric suction or a portable drainage
suction such as a Hemovac or Jackson Pratt; reduces the possible entry of microorganisms into the wound through
the drain
Suture- thread used to sew body tissues together; usually removed within 7 to 10 days after surgery
Review types and removal of sutures (pgs 972-974)
20

Review all skills for chapter 37


Chapter 15-Assessing Clients with Integumentary Disorders
The skin, hair and the nails make up the integumentary system. It is the largest organ in the body and provides an
external covering for the body, separating and protecting the bodys organs and tissues form the external environment.
Disorders of the integumentary structures may be caused by a variety of factors, including allergies, infection,
infestation, cancer and genetic influences.
Skin is about 15 to 20 square feet
Weighs about 9 pounds
Each square foot contains 15 feet of blood vessels, 4 yards of nerves, 650 sweat glands, 100 oil glands, 1500 sensory
receptors, and 3 million cells that are constantly dying and being replaced.
The skin consist of two main parts:
Epidermis- outermost part of the skin, consists of epithelial cells. It consist of five layers.
o Stratum basale- deepest layer its consists of melanin and kerotin
o Stratum spinosum- mitosis occurs at this layer
o Stratum granulosum- consists of glycolipid that slows water loss across the epidermis
o Stratum lucidum-is present only in thick areas of skin, it is made up of flattened, dead keratinocytes.
o Stratum corneum- top and thickest layer of skin
Dermis- is the second, deeper layer of skin. Made of a flexible connective tissue, this layer is richly supplied with
blood cells, nerve fibers, and lymphatic vessels. It also contains hair follicles, sebaceous glands, and sweat glands.
It has two layers papillary and recticular.
o Papillary- consists of ridges, capillaries and receptors for pain and touch
o Recticular- contains blood vessels, sweat and sebaceous glands, deep pressure receptors and dense bundles of
collagen fibers.
Superficial Fascia- fatty layer

Glands of the skin:


Sebaceous glands (Oil glands)- which secrete sebum that softens and lubricates the skin and hair, aids in the
prevention of water loss and protects the body from infection by killing bacteria.
Sudoriferous glands- (sweat glands)- 2 types appocrine and eccrine.
Ceruminous glands in ear to trap foreign materials
Skin color- is due to the amounts of melanin in the skin
Skin color is influenced by emotions and illneses.
Erythema- areddening of the skin, may occur with embarrassment, fever, hypertension, or inflammation
Cyanosis- bluish color of the skin, results from poor oxygenation of hemoglobin
Pallor- paleness of skin, may occur with shock, fear, or anger or in anemia and hypoxia.
Jaundice- is a yellow to orange color visible in the skin and mucous membranes; it is most often a result of
hepatic disorder
Hair- eyelashes protect the eyes, nose hairs protect foreign particle from entering the respiratory tract, hair on the
head protects the scalp form heat loss and sunlight.
Nails- protect fingers and toes
Diagnosis (look on page at chart).
Genetic considerations- Ask about integumentary disorders or abnormalities in immediate family members and their
gender.
Health Assessment Interview- Ask about onset, characteristics and course, severity, precipitating and relieving factors,
and note the timing and circumstances of any associated symptoms.
Look on page 429 for interview questions on the Integumentary System.
21

Look on page 430 Table 15-3 for Age Related Skin Changes
Look on page 430 Box 15-1 Common skin lesions of older adults
Look on page 431 Table 15-4 Terminology of Skin Lesions with Associated Disorders and below that integumentary
assessments
Primary Skin Lesions
Macule- flat, discolored, circumscribed lesion. Ex. (freckle), measles , and petechiae
Papule- elevated, solid, palpable mass with circumscribed border. Ex- wart pimple, moles <1cm in dia.
Nodule- elevated, solid, hard or soft palpable mass extending deeper into the dermis than a papule. (benign or
malignant). Ex- small lipoma, squamous cell carcinoma, fibroma, and intradermal nevi.
Wheal- elevated, often reddish area with irregular border caused by diffuse fluid in tissues father than free fluid in
a cavity, as in vesicles. Ex- insect bites and hives
Vesicle and Bulla- elevated lesion that contains fluid; bulla is a vesicle >0.5 cm. Ex- blisters, herpes
simplex/zoster, chickenpox, poison ivy, small burn blisters.
Pustule- elevated pus-filled vesicle or bulla with circumscribed border. Ex- acne, impetigo, and carbuncles(large
boils)
Cyst- Elevated, encapsulated mass of dermis or subcutaneous layers, solid or fluid filled. Ex- Sebaceous cyst
Secondary Skin Lesions
Fissure- small crack-like sore or break exposing the dermis. Ex- cracks in the corners of the mouth, or on the
hands, also in athletes foot
Excoriation- superficial loss of tissue resulting in skin lesion. Scratching, trauma, chemical, burns are all causes
Contusion- tissue damage without skin breakage (bruise)
Laceration- wound produced by tearing of body tissue, blow form blunt instrument, falling
Ulcer- Deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. May bleed.
May leave a scar. Ex- decubitus ulcer, stasis ulcers, chancres.
Scar- Flat, irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or
purple; older scars may be silvery or white. Ex- healed surgical wound or injury healed, healed acne.
Keloid- Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during
healing. More common in blacks.
Scales- heaped up particles of horny epithelium, shedding flakes of greasy, keratinized skin tissue. Color may be
white, gray, or silver. Texture may vary from fine to thick. Ex- dry skin, dandruff, psoriasis, and eczema.
Crusts- dry blood, serum, or pus left on the skin surface when vesicles or pustules burst. Ex- Eczema, impetigo,
herpes, or scabs following abrasion.
Erosion- focal loss of part or all of the epidermis. Heal without scarring. Ex- scratch marks and ruptured vesicles.
Lichenification- Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching
or rubbing. Ex- Chronic Dermatitis
Atrophy- translucent, dry, paper-like sometimes wrinkled skin surface resulting from thinning or wasting of the
skin due to loss of collagen and elastin. Ex- striae, aged skin
Vascular Skin Lesions
Spider Angioma- A flat bright red dot with tiny radiating blood vessels ranging in size from a pinpoint to 2cm. It
blanches with pressure.
Venous Star- A flat blue lesion with radiating, cascading, or linear veins extending from the center.
Petechiae- Flat red or purple rounded freckles
Purpura- flat, reddish blue, irregularly shaped extensive patches of varying size
Ecchymosis- bruises
Chapter 16 Study Guide
Pruritis- a subjective itching sensation that produces an urge to scratch
May occur in a small, circumscribed area, or it may involve a widespread area
22

May or may not be associated with a rash


Almost anything in the internal or external environment can cause pruritis
o Insects, animals, plants, fabrics, metals, medications, allergies, and emotional distress
May also occur as a secondary manifestation of systemic disorders
o DM, hepatic disease, and renal failure
o Heat and prostaglandins trigger pruritis and that histamine and morphine increase it
The person scratches or rubs the affected area
o Irritates the skin can cause further inflammation
Secondary effects of pruritis includes skin excoriation, erythema, wheals, changes in skin color, and infections
o Persistent pruritis may interrupt sleep patterns because it is more intense at night
o Long term may be debilitating and increases the risk of infection as excoriation occurs
Management focuses on identifying and eliminating the cause and providing medications to relieve the itch
o Antihistamines
o Tranqulizers
o Topical medications that have corticosteroids
o Therapeutic baths
o Doxepin-antidepressant, relieves itching by sedative effect
o Trimeprazine- relieves itching from eczema or poison ivy
o Never give Vistaril IV!!!
Xerosis- dry skin, most often the problem in the older adult
Decrease in the activity of sebaceous and sweat glands
Primary manifestation of dry skin is pruritis
How to relieve pruritis and dry skin:
o Wash clothing in a mild detergent and rinse twice no fabric softener
o Avoid using perfumes and lotions with alcohol
o Apply skin lubricants after a bath
o Use tepid water and a mild soap for a bath not hot
o Do not take a bath every day
o Use bath oils at the end of a bath
o Use a humidifier to humidify the air
o Apply lotions when the skin is slightly damp
o Increase fluid intake
o Cotton gloves may be worn at night
o Distraction or relaxation techniques may prove helpful
Keloids- elevated, irregularly shaped, progressively enlarging scars
Arise from excessive amounts of collagen in the stratum corneum during scar formation in connective tissue
repair
More common in young adults and appear in one year of trauma
Most commonly appear in African and Asian descents, there is also a familial tendency
Certain areas: chin, ears, shoulders, back, and lower legs
The swollen appearance of keloids is from excess extracellular material
They first appear as red, firm, rubbery plaques that persist for several months after the initial trauma
o Uncontrolled overgrowth over time causes the keloids to extend beyond the original scar, eventually it
becomes smooth and hyperpigmented
Nevi- moles, flat or raised macules or papules with rounded, well defines borders
Arise from melanocytes during early childhood with the cells initially accumulating at the junction of the dermis
and epidermis
over time the cluster of cells moves into the dermis and the lesion becomes visible
Almost ALL adults have nevi
Nevi range from flesh colored to black and occasionally contain hair
Can occur on any surface of the body and may arise as single lesions or in groups
23

Some pigmented lesions can become malignant

Angiomas- benign vascular tumors


Different Forms:
o Nevus flammeus (Port Wine Stain)- a congenital vascular lesion that involves the capillaries, on upper body
or face as macular patches that range from light red to dark purple, presented at birth
o Cherry Angiomas- small rounded papules that may occur at any age but most common in 40s and gradually
increase in number, red to purple, often found on the trunk
o Spider Angiomas- dilates superficial arteries, common in pregnant women and in clients with hepatic
disease, on face, neck, and upper chest, usually small bright red papules with radiating lines
o Telangiectasis- single dilated capillaries or terminal arteries that appear often on the cheeks and nose, older
adults and result from photoaged skin, look like broken veins
o Venous Lakes- small flat blue blood vessels, seen on exposed skin of the older adults such as ears, lips, and
backs of the hands
Skin tags- soft papules on a pedicle
Can be as small as a pinhead or as large as a pea and are most often found on the front or side of the neck and in
the axillae, as well as in the areas where clothing rubs the skin, normal skin color and texture
Keratosis- any skin condition in which there is a benign overgrowth and thickening of the cornified epithelium, most
often appear in adults at age 50
Seborrheic keratoses- superficial flat smooth or warty surfaced growths, 5-20mm in diameter, on face and trunk
o Lesions may be tan, waxy yellow, dark brown, or flesh colored, and often appear greasy
o Most often in older adult and do not appear to be related to damage from sun exposure, easily removed, no
scarring
Psoriasis- a chronic immune skin disorder characterized by raised, reddened, round circumscribed plaques covered by
silvery white scales
Size varies
May appear anywhere on the body, but they are most commonly found on the scalp, extensor surfaces of the arms
and legs, elbows, knees, sacrum, and around the nails
May disappear throughout life
Incidence is lower in warm sunny climates
Onset usually in the 20s, but it may occur at any age
More often in Caucasians
Sunlight, stress, seasonal changes, hormone fluctuations, steroid withdrawals, and certain drugs(alcohol,
corticosteroids, lithium, and chloroquine) appear to exacerbate this disorder
About 1/3 of clients have a family history of psoriasis
Trauma to the skin is also a precipitating factor, those lesions from surgery trauma are called Kobners reaction
Need to evaluate quality of life
Can have psoriatic arthritis
Psoriasis vulgaris is the most common form of psoriasis
o Can be found anywhere on the skin but most common on elbows, knees, and scalp
o Initially the lesions are papules that form into well defined erythematous plaques with thick, silvery white
scales
o The plaques in dark skinned people may appear purple
Treatments:
Diagnosis
o Skin biopsy may be done if the client presents with atypical manifestations or to differentiate psoriasis from
other inflammatory or infectious skin disorders
o Ultrasound may reveal typical psoriatic changes in the stratum corneum and inflammation of the dermis
Medications
o No cure, but treatment decreases the severity and pain of the lesions
24

Topical medications are administered to decrease inflammation, prolong the maturity time of keratinocytes
and increase remission time
o Corticosteroids, tar preparations, anthralin, and the retinoids are typically used; may often be taken
systemically or injected directly into the lesions; combined with other treatments
o Topical corticosteroids decrease inflammation, suppress mitotic activity of psoriatic cells and delay the
movement of keratinocytes to the surface of the skin
o Tar preparations (Estar, Psorigel, and Fototar) suppress mitotic activity and are also anti-inflammatory
o Topical anthralin inhibits the mitotic activity of epidermal cells and is effective in some cases of chronic,
localized psoriasis that do not respond to other topical agents; applied to the plaque at bedtime and left in
place for 8-12 hours
o Calcipotriene(Dovonex) a vitamin D analog has been effective and safe in both long term and short term
treatment of psoriasis; it inhibits cell proliferation in the epidermis and facilitates cell differentiation; Enbrelan antiTNF receptor medication may be given injection to decrease inflammation and psoriatic arthritis
Psoriasis that is generalized is difficult to treat with topical medications, so other treatments include:
o UV Light Therapy- UVB light is the treatment of choice for generalized psoriasis; it decrases the growth rate
of epidermal cells thereby decreasing hyperkeratosis
Light therapy is administered gradually increasing exposure times, until the client experiences mild
erythema, like a mild sunburn
o Photochemotherapy- a light activated form of the drug methoxsalen is used; it is an antimetabolite that
inhibits DNA synthesis and thereby prevents cell mitosis, decreasing hyperkeratosis
Exposure to UV rays activates the drug
Administered 2-3 times a week
Direct sunlight must be avoided 8-12 hours after
Has a high success rate in achieving remission of psoriasis but it can accelerate aging of exposed skin,
induce cataract development, alter immune function, and increase the risk of melanoma
General Guidelines for Applying Topical Medications:
Skin surface must be clean and dry
Remove old creams by washing the skin with tap water
To apply gels, creams, and pastes: squeeze about to 1in of the gel or cream into the palm of the hand; rub the
hands together until they are covered; apply gels and creams to the affected area with long strokes until the skin is
thinly covered
o Corticosteroids- applied 2-3 times a day in small amounts and rubbed directly onto the lesions; apply the
medication after a bath and cover with an occlusive dressing
o Apply medications containing tar in the direction of hair growth; do not apply these meds to the face, to the
genitals, or in skin folds; if the tar is water based or oil based it will stain clothing
o Wear gloves when applying anthralin stains
To apply lotions: shake the bottle of lotion well; pour a small amount into the palm of the hand, and pat the
medication onto the skin, if the lotion is thin use a gauze pad
To apply sprays: hold the container about 6 in from the skin, and apply the medication in a short spray
To apply medicated shampoo: rinse out medication from previous application; apply the shampoo massage into
the hair and over the scalp carefully and allow it to remain for the prescribed times; rinse out
To apply pastes: use enough paste on an applicator to cover the lesion thinly
Nursing Diagnosis for Skin:
Impaired Skin Integrity:
o Therapeutic baths
o Use warm not hot water
o Gently rub lesions with a soft washcloth using a circular motion
o Dry the skin with a soft towel by blotting or patting
o Keep skin lubricated at all times
o Apply in a thin layer
o Apply an occlusive dressing, for only 8 hours
o Applying a thin layer more frequently is often more effective than a single thick layer
o May cause maceration- skin breakdown due to prolonged exposure to moisture)
o

25

Disturbed Body Image:


o Establish a trusting relationship
o Encourage client to verbalize feelings
o Promote social interaction through family involvement in care, and referral to support groups of people with
psoriasis
Folliculitis- a bacterial infection of the hair follicle, caused by staph aureus
The bacteria releases enzymes and chemical agents that cause an inflammation
Lesions appear as pustules surrounded by and area of erythema on the surface of the skin
Lesions accompanied by discomfort ranging from slight burning to intense itching
Major complication is abscess formation
Seen most often on the scalp and the extremities, also seen on the face of bearded men(called sycosis barbae) and
on the legs of women who shave and on the eyelids called a stye
Furuncles- often called boils, are also inflammation of the hair follicle
Often begin as folliculitis but the infection spreads down the hair shaft through the wall of the follicle and into the
dermis
Initially a deep, firm, red, painful, nodule from 1-5 cm
After a few days, the nodule changes into a large painful cystic nodule
The cysts may drain substantial amounts of purulent drainage
One or more furuncles may occur on any part of the body that has hair
Contributing factors include poor hygiene, trauma to the skin, areas of excess moisture, and systemic
diseases(DM and hematologic tendencies)
Carbuncle- group of infected hair follicles
Lesion begins as a firm mass located in the subcutaneous tissue and the lower dermis; this mass becomes swollen
and painful and has multiple openings to the skin surface
Most often found on the back of the neck, upper back, and lateral thighs
May experience chills, fever, and malaise
Common in hot humid climates
Take antibiotics
Cellulitis- a localized infection of the dermis and subcutaneous tissue
Can occur following a wound or skin ulcer or as an extension of furuncles or carbuncles
The infection spreads as a result of a substance produced by the causative organism, called spreading factor; this
breaks down the fibrin network and other barriers that normally localize the infection
The area of cellulitis is red, swollen, and painful
Vesicles may form over the area of cellulitis
Client may experience fever, chills, malaise, HA, and swollen lymph glands

Erysipelas- an infection of the skin most often caused by group A strep


Chills, fever, and malaise are prodromal symptoms occurring from 4 hours to 20 days before the skin lesion
appears
The initial infection appears as firm red spots that enlarge and join to form a circumscribed, bright red, raised, hot
lesion
Vesicles may form over the surface of the erysipelas lesion
The area is usually painful, itches, and burns
Erysipelas most commonly appears on the face, ears, and lower legs
Most common kinds impetigo-bacteria in bite
Highly contagious
Medications:
The primary treatment for bacterial infections of the skin is an antibiotic specific to the organism
Diagnosis:
Risk for Infection
o Good hand washing
26

o Cover lesions with sterile dressing


Good nutrition
Prevent spread of infections
Dermatophytoses(Tinea)
Superficial fungal infections of the skin
Also known as ringworm
Fungal infections occur when a susceptible host comes in contact with the organism; may be transmitted through
direct contact with animals, other infected people or by inanimate objects
The most important factor in the development of an infection is moisture; skin folds, between toes, and in the
mouth
More common in warm humid climates
Types:
o Tinea Pedis- fungal infection of the soles of the feet, space between the toes, and or the toenails; Athletes
foot; most common type
Lesions vary from mild scaliness to painful fissures with drainage and they are usually accompanied by
pruritis and a foul odor
Infection is often chronic, absent in winter but reappearing in hot weather when perspiring feet are
encased in shoes
o Tinea Capitis- a fungal infection of the scalp; primary lesions are gray, bald, round spots, often
accompanied by erythema and crusting
Very contagious
Seen more often in children than in adults
o Tinea Corporis- a fungal infection of the body ; can be caused by several different fungi; and the lesions
vary according to the causative organism
Most common lesion is large circular patches with raised red borders of vesicles, papules, or pustules
Pruritis and erythema also present
o Tinea Versicolor- fungal infection of the upper chest, back, and sometimes the arms
Lesions are yellow, pink, or brown sheets of scaling skin
Patches do not have pigment and do not tan when exposed to UV light
This is normal flora but has altered immunity
Hypopigmentation
Hot climates and sweating
Adolescents and young men
o Tinea Cruris- a fungal infection of the groin that may extend to the inner thighs and buttocks
Often jock itch; often associated with tinea pedis and is more common in people who are physically
active, obese, or wear tight underclothing; men
Candidiasis- yeastlike fungal infection
Normally found on mucous membranes, on the skin, in the vagina, and in the GI tract
Fungus becomes a pathogen when the following factors encourage its growth:
o Local environment of moisture, warmth, or altered skin intergrity
o Administration of systemic antibiotics
o Pregnancy
o Use of birth control pills
o Poor nutrition
o The presence of DM, Cushings, or other chronic debilitating illnesses (HIV)
o Immunosupression
o Some malignancies of the blood
Affects outer layers of the skin and mucous membranes of the mouth, vagina, uncircumsized penis, nails, and
deep skin folds
As the infection spreads the accumulation of inflammatory cells and shedding of surface cells produce a white to
yellow curdlike substance that covers the infected area
Diaper rash; chelitis
27

Check blood sugars


Satellite lesions are characteristic of candidiasis
Medications:
Fungal infections of the skin are treated by topical or systemic antifungal medications
o Tinea capitis is treated by shampooing the hair 2-3 times a week, applying a topical antifungal to inactivate
organisms on the hair, and taking griseofulvin(Fulvicin) and antifungal agent
o Tinea pedis is treated by soaking the feet in Burrows solution, K permanganate solution, or saline solution to
remove crusts and scales; topical antifungals are applied to the infected areas for several weeks
o Mild cases of tinea cruris are treated with topical medications for 3-4 weeks
o Treated with oral medications or powder or vaginal suppositories
o Nystatin is an antibiotic effective in controlling the infection
o Diflucan an oral antifungal agent is also effective
Care:
Fungal diseases are contagious; do not share linens or personal items with others
Use a clean towel and washcloth each day
Carefully dry all skin folds including those under the breasts, under the arms, and between the toes
Wear clean underclothing each day
Fungi grow in moist environments such as on sweaty feet
Bathe more frequently and dry genital area well
Have sexual partner treated at the same time to avoid passing the infection back and forth to each other
Look at p450 Medication Administration
Pediculosis- an infestation with lice, parasites that live on the blood of an animal or human host
The louse is 2-4 mm oval organism with a stylet that pierces the skin; an anticoagulant in its saliva prevents host
blood from clotting while it eats
The female louse lays its eggs, called nits, in the hair shaft
After the egg hatches and reaches the adult stage it dies in 30-50days
Types of human pediculosis:
o Pediculosis Corporis- body lice; more common in people who do not have access for bathing or washing
clothes, such as the homeless
The lice live in clothing fibers and are transferred by contact with infested clothing and bed linens
Macules appear at first followed by wheals and papules
Pruruitis is common and scratching results in linear excoriations
Secondary infections cause hyperpigmentation and scarring; most often on shoulders, trunk, and
buttocks
o Pediculosis Pubis- pubic lice, often called crabs; this is spread through sexual activity with someone already
infested or by contact
Lice are found in the pubic region and occasionally spread to the axillae or mens beards
The lice cause skin irritation and intense itching
o Pediculosis Capitis- head lice; most often behind the ears and at the nape of the neck but may also spread to
other hairy areas of the body; eyebrows, pubic area, or beard
The lice are transmitted by contact with an infested person
Pruritis, scratching, and erythema of the scalp
If untreated the hair appears matted and crusted with a foul smelling substance
Scabies- a parasitic infestation caused by a mite
The pregnant female mite burrows into the skin and lays 2-3 eggs each day for about a month; they hatch in about
3-5 days and the larvae migrate to the surface but burrow into the skin for food and protection; the larvae develop
and the cycle repeats
Affects all people
Found in webs between the fingers, the inner surfaces of the wrist and elbows, the axillae, the female nipple, the
penis, the belt line, and the gluteal crease
Lesions are small redbrown burrow, sometimes covered with vesicles, which appears as a rash
Pruritis in response to the mite or its feces is common, especially at night and excoriations may develop
28

Predispose the person to secondary bacterial infections


Medications:
Lice are eradicated with agent that kill the parasite
Treated with topical medications
Infestations of pubic hair are treated with shampoos containing lindane
Head lice treated with cream called NIX
Warts- verrucae, are lesions of the skin caused by HPV
More than 60 types of HPV have been found on the human skin and mucous membranes
May be found on nongenital skin or genital skin and mucous membranes
Nongenital warts begin as lesions; genital warts may be precancerous
Transmitted through skin contact
May be flat, fusiform, or round; have a rough gray surface
Types:
o Common wart- appears anywhere on the skin and mucous membranes but most common on the fingers
o Plantar warts- occur at pressure points on the soles of the feet; the pressure of the shoes and walking
prevents these warts from growing outward so they tend to extend deeper beneath the skin surface than do
common warts; often painful
o Flat wart- small flat lesion, usually seen on the forehead or dorsum of the hand
o Condylomata acuminate- also called HPV or veneral warts occur in moist areas, along the glans of the
penis
Herpes Simplex- fever blister or cold sore; virus infections of the skin and mucous membranes are caused by 2 types
of herpesviru:HSV1 and HSV2
Most infections above the waist are caused by HSV-1, most often found on the lips, face, and mouth
HSV-2 infects the lining of the brain and has no symptoms
Virus may be transmitted by physical contact, oral sex, or kissing
Infection begins with burning or tingling sensation, followed by the development of erythema, vesicles formation,
and pain
The vesicles progress through pustules, ulcers, and crusting until healing occurs in 10-14 days
90% of adults have antibodies
Herpes Zoster- also called shingles, is a viral infection of a dermatome section of the skin caused by varicella
zoster(the herpes virus also causes chickenpox)
Most often affects adults over the age of 60
Clients with Hodgkins disease, certain types of leukemia, and lymphomas are more susceptible to an outbreak of
the disease
Medications:
Warts- depending on their size, location, and any associated discomfort, warts may be treated with medications,
cryotherapy, or electrodesiccation and curettage; acid therapy; duct tape
Herpes Simplex- treated with topical acyclovir, and antifungal agent; shortens the time of symptoms and speeds
healings
Herpes zoster- antiviral drugs are used to treat this; acyclovir interferes with viral synthesis and replication;
although it does not cure herpes infections, it does decrease the severity of the illness and also decreases pain
Diagnosis:
Acute Pain
o Teach measures to relieve pruritis
o Keep room cool
o Use a bed cradle to keep sheets off of body
Disturbed Sleep Pattern
o Releive pain and pruritis
o Cool environment
Risk for Infection
o Teach client signs of infection
29

o WBC
o Assess lymph glands
Dermatitis- an inflammation of the skin characterized by erythema and pain or pruruitis; may be acute or chronic
Contact Dermatitis- a type of dermatitis caused by a hypersensitivity response or chemical irritation
o The major sources known to cause this are dyes, perfumes, poison plants,chemicals, and metals
o One common in healthcare is latex dermatitis
Atopic Dermatitis- an inflammatory skin disorder that is also called eczema
o The exact cause is unknown, but related factors include depressed cell mediated immunity, elevated IgE
levels, and increased histamine sensitivity
o Seen more often in children but chronic forms persist throughout life
o Clients with atopic dermatitis have a family history of hypersensitivity reactions, such as dry skin, eczema,
asthma, and allergic rhinitis
o Although up to 1/3 of clients with atopic also have food allergies
Seborrheic Dermatitis- chronic inflammatory disorder of the skin that involves the scalp, eyebrows, eyelids, ear
canals, nasolabial folds, axillae, and trunk
o Seen in all ages, cradle cap, dandruff, dander
o Component of Parkinsons
o Seen in clients with AIDS also
Acne- a disorder of the pilosebaceous structure, which opens to the skin surface through a pore
Sebaceous glands produce sebum
Acne Vulgaris
o The form of acne common in adolescents and young to middle adults
o Possible causes include androgenic influence on the sebaceous glands, increased sebum, and proliferation of
the anes organism
o Most common of all skin conditions
o Face and neck, also on back, chest, and shoulders
o Women in 30s and 40s with no prior acne may develop popular lesions on chin and around mouth
Acne Rosacea
o A chronic type of facial acne that occurs more often in middle and older adults
o Lesions begin with erythema over the cheeks and nose
Acne Conglobata
o A chronic type of unknown cause that begins in middle adulthood
o Causes serious skin lesions, comeodnes, papules, pustules, nodules, cysts, and scars occur on back, buttocks,
and chest
o The comedones have multiple openings and a discharge that ranges from serious to purulent with a foul odor
Look at p459 Medication Administration
Nursing Care
o Wash the skin with a mild soap and water at least twice a day
o Shampoo hair often
o Eat a regular well balanced diet
o Expose skin to sun but avoid sunburn
o Get regular exercise and sleep
o Try to avoid putting hands in your face
o Do not squeeze a pimple
Nonmelanoma Skin Cancer
Risk factors:
o Fair skin, freckles, blue or green eyes, and blond or red hair
o Family history of skin cancer
o Unprotected and or excessive exposure to UV radiation
o Radiation treatment
o Occupational exposures to coal, tar, pitch, creosote, arsenic compounds, or radium
o Severe sunburns as a child
30

Basal Cell Cancer


An epithelial tumor believed to originate either from the basal layer of the epidermis or from cells in the
surrounding dermal structures
Types an Characteristics:
o Nodular-Face,neck,and head- small, firm papule, pearly white, pink, or flesh colored; enlarges; may ulcerate
o Superficial- trunk, extremities- papules or plaque that is flat; erythematous; or scaling; pink color; well
defined borders; may have shallow erosions and surface crusting
o Pigmented- head, neck, face- dark drown, blue, or black color; border is shiny and well defined
o Morpheaform- head, neck- looks like a flat scar; ivory or flesh colored
o Keratotic- ear- small firm papule; pearly white pink or flesh colored; may ulcerate
Characterized by erythema, ulcerations, and well defined borders
Squamous Cell Cancer
A malignant tumor of the squamous epithelium of the skin or mucous membranes
Occurs most often on areas of skin exposed to UV rays and weather, such as the forehead, helix of the ear, top of
the nose, lower lip, and back of the hands
Much more aggressive cancer than basal cell cancer
As a squamous cancer cell grows it tends to invade surrounding tissue, it also ulcerates may bleed and is painful
Preventing Skin Cancer:
Minimize sun exposure between the hours of 10am and 3pm when UV rays are the strongest
Cover up with a wide brimmed hat, sunglasses, long sleeved shirt, and long pants made of tightly woven materials
when in the sun
Apply a waterproof or water resistant sunscreen with an SPF of 15 or higher at least 30min before every exposure
to the sun, if swimming or sweating heavily, reapply every hour. Apply sunscreen not only on sunny days but also
on cloudy days
Use sunscreen and protective clothing when you are on or near sand, snow, concrete, or water
Avoid tanning booths, UV radiation emitted by tanning booths damages the deep skin layers
Nursing Care of Clients with Integumentary Disorders
Malignant Melanoma- this is a serious skin cancer is increasing in incidence each year.
This disease is 10 times more common fair-skinned people than in dark-skinned people and those who have had
severe sunburns with blistering during childhood and those who have precursor lesions (nevi)
Risk Factors Look at Box 16-7
Malignant melanomas arise form melanocytes, cells located at or near the basal layer (the deepest epidermal layer
The prognosis for survival for people diagnosed with malignant melanoma is determined by several variables,
including tumor thickness, ulceration, metastasis, site, age, and gender.
Tumors on the hands, feet, and scalp have a poorer prognosis; tumors of the feet and scalp are less visible and
may not be diagnosed until they grow into the dermis.
Identification (ABCD Rule)
o A= asymmetry (one half of the nevus does not match the other half)
o B= border irregularity (edges are ragged, blurred, or notched
o C= color variation or dark black color
o D= diameter greater than 6mm (size of a pencil eraser)
Diagnosis
o Because malignant melanoma may metastasize to any organ or tissue of the body, a variety of test may be
conducted, including microscopic examination, biopsy and test for metastasis (liver function tests and
computed tomography scan of the liver, a CBC, serum blood chemistry profile, chest x-ray, bone scan, and
CT scan or MRI of the brain.
Microstaging
o Microstaging- describes the assessment of the level of invasion of a malignant melanoma and the maximum
tumor thickness.
o The American Joint Committee on Cancer has adopted a four-stage system that includes tumor thickness,
level of invasion, lymph node involvement, and evidence of metastasis.
31

Treatment
o Surgical excision- is the preferred treatment for malignant melanoma. If a biopsy identifies the lesion as a
melanoma, a wide excision is performed that includes the full thickness of the skin and subcutaneous tissue.
Because the risk of local recurrence for thin melanomas (those less than 0.76 mm) is quite low, margins of 0.5
to 1.0 cm of normal skin are excised around the tumor. Thick tumors require a 1-3 cm margin excision
because they are at risk for local recurrence or satellite lesions.
o Immunotherapy- interleukins and interferons
o Radiation therapy- Melanoma responds to higher dose radiation, especially if the tumor is small. Response
rates to radiation therapy depend on the site of the tumor, the thickness of the tumor, the type of melanoma,
and the clients general health. Liver and lung metastasis are not treated with radiation therapy because a loss
of organ function may result.
Health Promotion
o The American Cancer Society recommends that people between the ages of 20 and 40 see a skin specialist
every 3 years and those over 40 annual.
o When self-assessing for melanoma, the client looks for a change in:
Color, especially any lesion that becomes darker or variegated in shades of tan, brown, black, red, white,
or blue.
Size, especially any lesion that becomes larger or spreads out
Shape, especially any lesion that protrudes more form the skin or begins to have an irregular outline
Appearance of lesion, especially bleeding, drainage, oozing, ulceration, crusting, scaliness, or
development of a mushrooming outward growth.
Consistency, especially any lesion that becomes softer or is more easily irritated
Skin around a lesion, such as redness, swelling, or leaking of color form a lesion into the surrounding skin
Sensation, such as itching or pain.
Nursing Diagnoses for patients with skin cancers
o Impaired Skin Integrity
Monitor for manifestations of infection
Keep the incision line clean and dry
Follow principles of medical and surgical asepsis when caring for clients incision.
Encourage and maintain adequate caloric and protein intake in the diet.
o Hopelessness
Provide an environment that encourages the client to identify and express feelings, concerns, and goals:
Encourage active participation in self-care as well as in mutual decision making and goal setting.
Encourage a focus not only on the present but also on the future
o Anxiety
Provide reassurance and comfort
Decrease sensory stimuli by using short, simple sentences; focusing on here and now; and providing
concise information
Provide interventions that decrease anxiety levels and increase coping
The client with a Pressure Ulcer
o Pressure ulcers- are ischemic lesions of the skin and underlying tissue caused by external pressure that
impairs the flow of blood and lymph. The ischemia causes tissue necrosis and eventual ulceration.
o They develop over bony prominences, but they appear on the skin of any part of the body subjected to
external pressure, friction, or shearing.
Pressure Ulcer Risk Factors
o Limited mobility
o Older adults
o Poor nutrition and hydration
Stages of Pressure Ulcers
o Stage I- Nonblanchable erythema of intact skin
o Stage II- Partial thickness skin loss, abrasion, blister, shallow crater
32

Stage III- Full thickness skin loss; damage to subcutaneous, deep crater
Stage IV- Full thickness skin loss; with extensive destruction, tissue necrosis, or damage to muscle, bone, or
supporting structures. Sinus tracts may also be associated with stage IV ulcers
Care for Patients with Ulcers
o Medications- topical or systemic antibiotics specific to the infectious organism eradicate any infection
present. Additionally, a variety of topical products promote healing.
o Surgical Treatment- Surgical debridement may be necessary if the pressure ulcer is deep; if subcutaneous
tissues are involved; or if an eschar scab or dry crust that forms over skin damaged by burns, infections, or
excoriations have formed over the ulcer, preventing healing by granulation. Large wounds may require skin
grafting for complete closure.
o Look at Table 16-4 on page 474 (Products used to treat Pressure Ulcers)
o Look at Nursing Research on pg 475
Frostbite- is an injury of the skin from freezing
Cutaneous Surgeries and Procedures
o Fusiform excision
The removal of a full thickness of the epidermis and dermis, usually with a thin layer of subcutaneous
tissue
It is used to remove tissue for biopsies and for complete removal of benign and malignant lesions of the
skin
Most fusiform excisions have a length to width ratio of 3-1
o Electrosurgery
Involves the destruction or removal of tissue with high frequency alternating current
A variety of surgical procedures may be performed including electrodesicattion, electrocoagulation, and
electrosuction
Used to remove benign surface lesions such as skin tags,keratoses, warts and angiomas
Also used to produce hemostasis for capillary bleeding
Used to remove telangiectases, warts, and superficial nonmelanoma skin cancers
Used to make incisions, excise tissue, and perform biopsies
o Cryosurgery
The destruction of tissue by cold or freezing with agents such as fluorocarbon sprays, carbon dioxide
snow, nitrous oxide, and liquid nitrogen
Used to treat many skin lesions
The freezing agents are applied topically to the lesion
o Curettage
The removal of lesions with a curette
The design of the curette allows it to cut through soft or weak tissue, but not through normal tissue
It is used primarily to remove benign and malignant superficial epidermal lesions
Benign lesions removed by curettage include keratoses, nevi, and angiomas
Nonmelanomas skin lesions are removed by curettage if they are small, well defined primary tumors
Curettage is also used to remove specimens of tissue for biopsy
o Laser Surgery
Used to treat clients with a wide variety of skin disorders, including port wine stains, telangiectases, and
venous lakes
A laser is an intense light that produces a thermal injury on contact with tissue
The injury causes coagulation, vaporization, excision, and ablation
o Chemical Destruction
The application of a specific chemical to produce destruction of skin lesions
Chemical destruction is used to treat both benign and premalignant lesions
Chemical is applied to the lesion or is used to cause peeling
After application, the treated area forms a thin crust that sloughs off in about a week
o Sclerotherapy
o
o

33

The removal of benign skin lesions with a sclerosing agent that causes inflammation with fibrosis of
tissue
Agents that cause therapeutic sclerosis include aethoxysclerol and hypertonic sodium chloride
This type of treatment is used for telangiectasis and superficial spider veins of lower extremities
The solution is injected into the affected veins causing a reaction that closes the lumen of the vein
Plastic Surgery
o The alteration, replacement, or restoration of visible portions of the body, performed to correct a structural or
cosmetic defect
o Cosmetic surgery- also aesthetic surgery, is one of two fields within plastic surgery
It enhances the attractiveness of normal features
o Skin grafts and flaps
Used to restore function while also maintaining and acceptable appearance
Both of these procedures involve the movement of skin from one part of the body to another part
Skin grafts- a surgical method of detaching skin from a donor site and placing it in a recipient site, where
it develops a new blood supply from the base of the wound; an effective way to cover wounds that have a
good blood supply, are not infected, and in which bleeding cannot be controlled
- Split Thickness Graft- contains epidermis and only a portion of dermis of the donor site
- A common donor site for a skin graft is the anterior thigh
- Full Thickness Graft- contains both epidermis and dermis; the layers contain the greatest number of
skin elements and are best able to withstand trauma; areas of thin skin are the best donor sites for full
thickness skin grafts; the donor site must be surgically closed and will scar
- Skin Flap- a piece of tissue whose free end is moved from a donor site to a recipient site while
maintaining a continuous blood supply through its connection at the base or pedicle
- Flaps carry their own blood supply; used for reconstruction or closure of large wounds
o Chemical Peeling- the application of a chemical to produce a controlled and predictable injury that alters the
anatomy of the epidermis and superficial dermis
The result is skin that appears firmer smoother and less wrinkled
This form of cosmetic surgery is more useful in people who have fair, thin skin with fine wrinkling
o Liposuction- a method of changing the contours of the body by aspirating fat from the subcutaneous layer of
tissue
This treatment is used to remove excess fat from the buttocks, flanks, abdomen, thighs, upper arms,
knees, ankles, and chin
It is not a cure for obesity
The procedure is usually done for younger clients because their skin is more elastic
Outpatient or inpatient
o Dermabrasion- a method of removing facial scars, severe acne, pigment from unwanted tattoos
The area is sprayed with a chemical to cause light freezing and is then abraded with sandpaper or a
revolving wire brush to remove the epidermis and a portion of the dermis
o Facial Cosmetic Surgery:
Rhinoplasty- improve the appearance of the external nose; the nasal skeleton is reshaped; and the
overlying skin and subcutaneous tissue are allowed to redrape over the new framework; resection of the
nasal septum
Blepharoplasty- loose skin and protruding periorbital fat is removed from the upper and lower eyelids
Rhytidectomy- facelift; a cosmetic surgery done to improve appearance by removing excess skin from the
face and neck
Diagnosis:
o Impaired Skin Integrity
Monitor incisions and grafts, and flap donor and recipient sites, for manifestations of infection and
necrosis
- Take and record VS
- Monitor all wounds
Provide care for donor site
- Position client to minimize pressure on the donor site

34

Use a bed cradle for linens


If the donor site is left open, and a heat lamp is to be applied, 2feet from the wound
Diet high in protein, ascorbic acid, vitamins, and mineral
Change dressings as prescribed or if the frequency is not indicated, determine which dressings are not
to be removed during the healing process and which are to be changed, and whether the wound is to
be kept dry or moist
o Acute Pain
Administer pain medications
Use alternative pain relief measures as appropriate, such as ice bags or cold compresses
Teach noninvasive methods of pain relief, such as deep breathing, relaxation, and guided imagery
o Disturbed Body Image
Hirsutism- hypertrichosis, the appearance of excessive hair in normal and abnormal areas of the body in women
o Most often occurs in a male distribution in women
o The excess hair is primarily the result of an increase in androgen levels
Alopecia- loss of hair, baldness
o May result from scarring, various systemic diseases, or genetic predisposition
o Systemic diseases that may cause alopecia are lupus, thyroid, pituitary insufficiency
o Male pattern baldness- the most common cause of alopecia in men and is genetically predetermined
o Female pattern baldness- begins in women in their 20s and 30s with progressive thinning and loss of hair over
the central part of the scalp
o Alopecia areata- round or oval bald patches on the scalp as well as on other hairy parts of the body
o Alopecia totalis- the loss of all hair on the scalp, irreversible
o Alopecia universalis- total loss of hair on all parts of the body
o Medications Causing:
Thalium
Retinoids
Anticoagulants
Antimitotic agents
Antithyroid
Birth Control
Trimethadione
Excess use of Vitamin A
Allopurinol
Propanolol
Indomethacin
Amphetamines
Salicylates
Levodopa
Gentamycin
Chemotherapy

35

Onchyolosis- separation of the distal nail plate from the nail bed; occurs most often in the fingernails; may result
from many different factors, including excessive or prolonged exposure to water soaps, detergents, alkalies, and
industrial agents, thyroid disorders
Paraonchyia- an infection of the cuticle of the fingernails or toenails; the disorder often follows a minor trauma
and secondary infection with staph, strep, Candida; begins with a painful inflammation that may progress to an
abscess; frequent exposure to water;
Onchymycosis- a fungal or dermatophyte infection of the nail plate; the nail plate elevates and becomes yellow or
white; psoriasis infections of the nail plate cause the nails to pit
Ingrown toenail results when the edge of the nail plate grows into the soft tissue of the toe; pain and infection may
occur; may spread to the bone if untreated; especially dangerous for people with DM or peripheral vascular
disease
Chapter 17

Burn wounds- occur when there is contact between tissue and an energy source, such as heat, chemicals, electrical
current, or radiation
the resulting effects of the burn are influenced by the: intensity of the energy; duration of exposure; type of tissue
injured
Burn Statistics:
At least 50% of all burn accidents can be prevented
Children playing with fire account for more than 1/3 of preschool deaths by fire
In the US, approx. 2.4 million burn injuries are reported each year
Burn injuries are second to motor vehicle accidents as leading causes of accidental death in the US
Older adults and children (esp. preschool aged children) account for 2/3 of all burn fatalities
The major cause of fires in the home is carelessness with cigarettes
Other causes of burn injuries:
o Hot water from water heathers set at high levels above 140 degrees F (60 degrees C)
o Cooking accidents
o Space heaters
o Combustibles-gasoline, lighter fluids, etc.
o chemicals
prevention can happen through educations
o nurses can teach home safety such as smoke alarms, need of fire extinguishers, and planned escape routes
Fire injuries and deaths that occur among college-age students usually are due to alcohol use that impairs
judgment and hampers escape
Older adults are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception,
sense of smell, and hearing, in addition to impaired mobility
Types of Burns
Thermal burns- can be caused by flames (dry heat), flash, scald, or contact with hot objects; also caused by frost
bite
o Most common type
o Results from residential fires, automobile accidents, playing with matches, improperly stored gasoline, space
heaters, electrical malfunctions, arson, inhaling smoke, steam, dry heat (fire), wet heat (steam), radiation, sun,
etc.
o Direct exposure to the source of heat causes cellular destruction that can result in charring of vascular, bony,
muscle, and nervous tissue
o Cold thermal injury- can be localized (ex: frostbite) or systemic (hypothermia)
Chemical burns (2 types)
o Acids- can be neutralized
36

Alkaline- adheres to tissue, causing protein hydrolyses and liquefaction (usually worse b/c they adhere to the
tissue); ex: cleaning agents, drain cleaners, and lyes
o With chemical burns, tissue destruction may continue for up to 72 hours afterward
o It is important to remove the person from the burning agent or vice versa
o The latter is accomplished by lavaging the affected area with copious amounts of water
Electrical burns
o Injury from electrical burns results from coagulation necrosis that is caused by intense heat generated from an
electric current
o Can cause tissue anoxia and death
o The severity depends on amount of voltage, tissue resistance, current pathways, and surface area in contact
with the current and length of time the current flow was sustained
o Electrical injury can cause:
Fractures of long bones and vertebra
Cardiac arrest or arrhythmias-can be delayed 24-48 hrs after injury
Severe metabolic acidosis-can develop in minutes
Myoglobinuria- acute renal tubular necrosis; myoglobin released from muscle tissue whenever massive
muscle damage occurs, goes to kidneys, and can mechanically block the renal tubules due to the large size
o Treatment of electrical burns:
Give fluids- RL or other fluids to flush out kidneys; give 75-100 cc/hr until urine sample is clear
an osmotic diuretic (Mannitol) may be given to maintain urine output
different types of burns
o 1st degree burn- outer skin layer is burned
o 2nd degree burn- middle skin layer is burned
o 3rd degree burn- deep skin layer is burned
Smoke and Inhalation injury
can damage the tissues of the respiratory tract
although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis
closes as a protective mechanism
3 types of smoke and inhalation injuries
1. Carbon monoxide poisoning
o CO poisoning and asphyxiation count for majority of deaths
o can occur without any burn injury to the skin
o Treatment- 100% oxygen; draw carboxyhemoglobin level
2. Inhalation injury above the glottis
o Caused by inhaling hot air, steam, or smoke
o Mechanical obstruction can occur quickly (true emergency)
o Watch for facial burns, singed nasal hair hoarseness, painful swallowing, and darkened oral or nasal
membranes
o Thermally produced
3. Inhalation injury below glottis
o Usually chemically produced
o Amount of damage related to length of exposure to smoke or toxic fumes
o Can appear 12-24 hrs after burn
Classification of Burn Injury
Treatment of burns is directly related to the severity of injury
Severity is determined by:
Depth of burn- determined by the elements of the skin that have been damaged or destroyed
Superficial burns- involves only the epidermal layer; most often results from sunburns, UV light, minor
flash injury, or mild radiation burn assoc. with cancer treatment
Partial-thickness burns- 2 types
o

37

Superficial partial-thickness burn- involves the entire dermis and the papillae of the dermis; causes
are flash flame or dilute chemical agents or contact with a hot surface
- Deep partial-thickness burn- involves the entire dermis but extends further into the dermis than a
superficial partial-thickness burn
- Are pink to cherry red, wet, shiny with serous exudates
- May or may not have intact blisters and are very painful when touched or exposed to air
full-thickness burns- involves all layers of the skin, including the epidermis, the dermis, and the
epidermal appendages; burn wound may extent into the subcutaneous fat, connective tissue, muscle, and
bone
- will be dry and waxy white to dark brown
- will have little to no sensation b/c nerve endings have been destroyed
What is the fxn of the integumentary system?
- Protective
- Holds in fluids and electrolytes
- Regulates heat
- Keeps harmful agents from injuring or invading the body
extent of burn- calculated in % of total body surface (TBSA); 2 common guidelines:
Lund-Browder Chart-(pg. 492 figure 17-6) more accurate than the rule of nine b/c it accounts for
changes in body surface area across the life span
rule of nine-(pg. 491 figure 17-5) rapid method of estimation used during the pre-hospital and
emergency care phase
- The body is divided into 5 surface areas (head, trunk, arms, legs, and perineum) and percentages that
equal or total a sum of 9s are assigned to each body area
- In small children, relatively more area is taken up by the head and less by the lower extremities so the
rule of nine is modified
Location of burn
Has a direct relationship to the severity of the burn
Face, neck, and chest burns may inhibit respiratory illness r/t mechanical obstruction secondary to edema
or eschar formation
Patient risk factors
Older adults heals slower & had more difficulty with rehab
Common complications are:
- Infection and pneumonia
- Preexisting illnesses: cardiovascular, pulmonary, or renal disease
- DM or PVD is at increased risk for gangrene & poor healing
Burn wound healing
Burns heal using the same processes as do other wounds but the wound healing phases occur more slowly and last
longer
3 phases of wound healing:
o Inflammation- immediately follows the injury
o Proliferation- happens within 2-3 days postburn
o Remodeling- may last for years, formation of scars happen in this stage; 2 types of scars
Hypertrophic scar- an overgrowth of dermal tissue that remains within the boundaries of the wound
Keloid- a scar that extends beyond the boundaries of the original wound
The client with a minor burn
minor burns consist of superficial burns that are not extensive
the usually treated in an outpatient facility
goal of therapy is to promote wound healing, eliminate discomfort, maintain mobility, and prevent infection
types of minor burns:
o sunburns
result from exposure to UV light
are superficial injuries
38

more commonly seen in pts with lighter skin


manifestations are usually mild and are limited to: pain, nausea, vomiting, skin redness, chills, and
headaches
treatment: applying mild lotions, increasing liquid intake, administering mild analgesics, and maintaining
warmth
older adults should be monitored for dehydration
o scald burns
result from exposure to moist heat and involve superficial and superficial partial-thickness burns
goal of therapy is to prevent wound contamination and promote healing
teach the pt to apply antibiotic solutions and light dressings and to maintain adequate nutritional intake
mild analgesics may be ordered to help the pt carry out ADLs
tetanus toxoid is administered as needed
o nursing care
tetanus shots should are recommended for all pts whose immunization histories are in doubt
minor burns with blisters may be left intact or debrided
follow-up care includes BID wound cleansing with application of topical ointment, ROM exercises to
affected joints, and weekly clinic appointments until the wound heals completely
Client with a major burn
a major burn involves serious injuries to the underlying layers of the skin and covers a large body surface
the American burn association classifies a major burn as:
o > 25% TBSA in adults less than 40 yrs old
o >20% TBSA in adults more than 40 yrs old
o >10% TBSA full-thickness burns
o Injuries to the face, eyes, ears, hands, feet , joints, or perineum
o High-voltage electrical injuries
o All burn injuries with inhalation injury or major trauma
The pathophysiologic changes that result from major burn injuries involve all body systems:
Integumentary System (emergent phase)
o The loss of skin in burn injuries interrupts normal skin fxns and it s protective mechanisms
o the key mechanisms lost in burn injuries include the prevention of evaporative water loss and bacteria entry,
as well as the maintenance of body warmth
Cardiovascular System (emergent phase)
o arrhythmias, hypovolemic shock which may lead to irreversible shock
o circulation to limbs can be impaired by circumferential burns and then the edema formation
o causes: occluded blood supply thus causing ischemia, necrosis, and eventually gangrene
o escharotomies (incisions through eschar) done to restore circulation to compromised extremities
o the effects of a major burn are manifested in all components of the vascular system, and include hypovolemic
shock (burn shock), cardiac dysrhythmias (such as ventricular fibrillation), cardiac arrest, and vascular
compromise
o hypovolemic shock (burn shock)
occurs when there is a loss of intravascular fluid volume
the volume is inadequate to fill vascular space and is unavailable for circulation
also, burns have a direct loss of fluid due to evaporation
there is a massive amount of fluid shifts from the intracellular and intravascular compartments into the
interstitium
this continues until capillary integrity is restored (usually w/in 24-36 hours of the injury)
o cardiac rhythm alterations
burns of more than 40% TBSA cause significant myocardial dysfunction, with a decrease in myocardial
contractibility and cardiac output
o peripheral vascular compromise

39

direct heat damage to extremities, especially if circumferential burns are present, results in damage to
blood vessels
Respiratory System (emergent phase)
o Vulnerable to 2 types of injury:
Upper airway burns- cause edema formation and obstruction of the airway
Inhalation injury- can show up 24 hrs later; watch for resp. distress such as increased agitation or change
in rate or character of resp.
- It is a frequent and often lethal complication of burns
- Injuries may range from mild respiratory inflammation to massive pulmonary failure such as acute
respiratory distress syndrome
Preexisting problem (ex: COPD) more prone to get resp. infection
- Pneumonia is common complication of major burns
- possible to overload w/ fluids, leading to pulmonary edema; nurse should listen for crackles & rales
GI System (emergent phase)
o Dysfunction of the GI system is directly related to the size of the burn wound
o Pts with >20% TBSA experience decreased peristalsis with resultant gastric distention and increased risk of
aspiration
o Stress ulcers (Curlings ulcers) are also formed after a burn
Urinary System (emergent phase)
o b/c of hypovolemic state, blood flow decreases, causing renal ischemia; if continued acute renal failure may
develop
Immune System (emergent phase)
o Skin barrier destroyed and all changes make the burn pt more susceptible to infection
o Pt may be in shock from pain and hypovolemia
o The period of vulnerability is transient and may last for 1-4 weeks following the burn
o During this time frame opportunistic infections can be fatal despite aggressive antimicrobial therapy
3 Phases of Burn management
Emergent/Resuscitative Stage
o This stage lasts from the onset of injury through successful fluid resuscitation (5 or more days) but usually
lasts 24-48 hrs
o Begins with fluid loss and edema formation and continues until fluid motorization and dieresis begins
o Greatest initial threat is hypovolemic shock to a major burn pt; treat shock by maintaining fluid volume
o Pt is assess for shock and evidence of respiratory distress
o If indicated IV lines are inserted and the pt may be prophylactically intubated
o During this stage healthcare workers determine whether the client is to be transported to a burn center
Acute Stage
o Begins with the start if dieresis and ends with closure of the burn wound (either by natural healing or by use
of skin grafts)
o Pt is no longer grossly edematous due to fluid mobilization, full and partial thickness burns more evident,
bowel sounds return, pt is more aware of pain and condition
o Healing begins when WBCs have surrounded the burn and phagocytosis begins, necrotic tissue begins to
slough, fibroblasts lay down matrices of collagen precursors to form granulation tissue
o Partial-thickness burns (if kept free from infection) will heal from edges and from below (10-14 days)
o Full-thickness burns must be covered by skin grafts
o during this stage wound care management, nutritional therapies, and measures to control infectious processes
are initiated
o hydrotherapy and excision and grafting of full-thickness wounds are performed s soon as possible after injury
o complications of acute stage
infection- due to destruction of the bodys 1st line of defense
- partial thickness wounds can convert to full-thickness wounds with infection present
- pt may get sepsis from wound infections

40

signs of sepsis: high temp, increased pulse & resp., decreased BP, decreased urinary output, mild
confusion, chills, malaise, and loss of appetite
- infections usually gram neg. bacteria (pseudomonas, proteus)
obtain cultures from a possible sources: IV, foley, wound, oropharynx, and sputum
cardiovascular- same as in emergent phase
neurologic- possible from electrical injuries
musculoskeletal- has the most potential for complication during acute phase due to healing and scare
formation making skin less supple and pliant; ROM limited, contractures can occur
GI- a dynamic ileus results from sepsis, diarrhea or constipation (RT narcotics & decreased mobility),
gastric ulcers RT stress, occult blood in stools possible
o Nursing management in acute stage
Predominant therapeutic intervention are:
- Fluid replacement, physical therapy, wound care, early excision and grafting, and pain management
Fluid replacement continues from emergent phase to acute phase; given for: fluid loss, administer
medications, and for transfusions
Physical therapy- to maintain optimal joint fxn
Pain management- most critical fxn as a nurse
Nutritional therapy-provide adequate protein and calories
Wound care- the goals are cleanse and debride the area of necrotic tissue and debris, minimize further
damage to viable skin, promote pt comfort, and re-epithelialization or success with skin grafting
Care for donor site and other graft necessary
Excision and grafting- eschar removed to subcutaneous tissue or fascia, graft applied to tissue
- Cultured epithelial autograft (CEA) uses pts own cells to grow skin-permanent
- Artificial skin is the latest trend (ex: alloderm, life-skin, etc)
Rehabilitative Stage
o Begins with wound closure & ends when the pt returns to the highest level of health (may take years)
o Can occur as early as 2 weeks to as long as 2-3 months after the burn injury
o Primary focus is the biopsychosocial adjustment of the pt, specifically the prevention of contractures and
scars and the pts successful resumption of their regular life
o The pt is taught to perform ROM exercises to enhance mobility and to support injured joints
o Clinical manifestations
Burn wound with heals by primary intention or by grafting
Scares may for and contractures
Mature healing is reached in 6 months-2 yrs
Avoid direct sunlight for 1 yr on burn
Now skin sensitive to trauma
o Complications
most common complications of burn injury are skin and joint contractures and hypertrophic scarring
b/c of pain, pts will assume flexed position; which predisposes wounds to contracture formation
use of physical therapy, pressure garments, splints, etc. are used
o Nursing Management
Must be directed to returning pt to society, address emotional concerns, spiritual and cultural needs, selfesteem, teaching of wound care management, nutrition, role of exercises and physical therapy explained
Common emotional response is regression
Prehospital Pt Management
Treatment at the injury scene includes measures to limit the severity of the burn and support vital fxns
Once the safety of the rescuers has been est. all prehospital interventions are aimed at eliminating the heat source,
stabilizing the pts condition, identifying the type of burn, preventing heat loss, reducing wound contamination,
and preparing for emergency transport.
Stop the burning process
o Emergency measures by the type of injury include the following:
41

Thermal burns
- if caused by dry heat- smother inflamed clothing or lavage with water
- help person to stop drop and roll to extinguish the flames and limit the extent of burn
- when flames are out cover body to prevent hypothermia
- if caused by moist heat- lavage the area with cool water
Chemical burns
- Immediately remove clothes and use a hose or shower to lavage the involved areas thoroughly for a
minimum of 20 min
- If it is a dry chemical (powder form) remove as much powder as possible before washing
Electrical burns
- Ensure that the source of electrical current has been disconnected or move the person to safely and
away from the energy source using a nonconductive device (unpainted broomstick)
- If person is unresponsive assess for the presence of cardiac and respiratory fxn
- If indicated begin CPR
Radiation burns
- Usually minor burns that involve only the epidermal layer
- Treatment focuses on helping normal body mechanisms promote wound healing
- All interventions are aimed at shielding, establishing distance, and limiting the time of exposure to
the radioactive source
Support vital functions
o if the thermal burn is large- focus on the ABCs
A=airway- check for patency, soot around nares, or signed nasal hairs
B=breathing- check for adequacy of ventilation
C=circulation- check for presence and regularity of pulse
o if pt has no pulse and is not breathing begin CPR
o position the pt with the head elevated at >30 degrees and administer 100% humidified oxygen by face mask
o monitor for cardiac dysrhythmias or arrest
o initiate fluid replacement therapy for burn wounds that involve more than 20% of the TBSA
o cover the pt to maintain body temp and to prevent further wound contamination and tissue damage
Emergency and Acute Care
During this phase the nurse obtains a hx of the injury, estimates the depth and extent of the burn, begins fluid
resuscitation, and maintains ventilation according to protocol
Fluid resuscitation
o The administration of IV fluids to restore the circulating blood volume during the acute period of increasing
capillary permeability
o 1 or 2 large bore IV replacement lines (may need jugular or subclavian)
o Cutdown rare RT increased risk of infection & sepsis
o Fluid replacement based on: size/depth of burn, age of pt, & individualized considerations (dehydration in
preborn state, chronic illness)
o Options- RL (usually seen), D5NS, dextam, albumin, etc.
o There are formulas for replacement: Parkland formula and Brooke formula
o 50% of the fluid should be infused during the 1st 8 hrs then the remaining 50% during the next 16 hrs
Respiratory Management
o Maintain the HOB at 30 degrees or greater to maximize the pts ventilator efforts
o Keep airway passages clear by suctioning the pt frequently, encourage the pt to use incentive spirometry
hourly, and help the pt perform coughing and deep-breathing exercises q 2 hr
o In the face of impending airway obstruction the pt will require immediate intubation
o Humidification of either room air or oxygen helps prevent the drying of tracheal secretions
o Medications to dilate constricted bronchial passages are administer IV and inhalants to control bronchospasms
and wheezing
o Arterial line is placed in the pt with major burn for continuous assessment of ABGs
o Pain meds are administered if the pt is not in shock
42

Inflammation and Healing


Burn injures cause coagulation necrosis where by tissues and vessels are damaged or destroyed
Wound repair begins within the first 6-12 hrs after injury
Fluid shifts (2nd spacing)
Massive fluid shifts out of blood vessels as a result of increased capillary permeability
When capillary walls become more permeable, water, Na, and later plasma proteins (esp. albumin) moves into
interstitial spaces and other tissues
The colloidal osmotic pressure decreases with loss of protein from the vascular space
*3rd spacing* fluids go into areas with no fluids; ex: exudates ad blister formation
Diagnosis
The following diagnostic tests are used to evaluate the pts progress and to modify intervention strategies:

o
o
o

o Urinalysis
o CBC
o Serum electrolytes
Renal function
creatine phosphokinase (CPK)
serial ABGs

o pulse oximetry
o serial chest x-ray studies
o serial 12-lead electrocardiograms (EKGs)
Total protein, albumin, transferring, prealbumin,
retinol binding protein, alpha one-acid glycoprotein,
and C-reactive protein

Laboratory values
o Sodium
Hyponatremia can occur due to: silver nitrate topical ointments as a result of Na loss through eschar,
hydrotherapy, excessive GI drainage, diarrhea, excessive water intake
- S&S of hyponatremia: weakness, dizziness, muscle cramps, fatigue, HA, tachycardia, and confusion
Hypernatremia can occur: too much hypertonic fluids, improper tube feedings, inappropriate fluid
administration
- S&S: thirst, tried furry tongue, lethargy, confusion, and possible seizures
o Potassium
Hyperkalemia is noted if pt is in renal failure, anrenocartical insufficiency, or massive deep muscle injury
with lg. amounts of potassium released from damaged cells
Cardiac arrhythmias and ventricular failure can occur if K+ level is >7 mEq/L
Muscle weakness and EKG changes are noted
Hypokalemia is noted with silver nitrate therapy and long hydrotherapy; other causes: vomiting diarrhea,
prolonged GI suction, prolonged IV therapy without K+ supplementation; constant K+ losses occur
through the burn wound
Wound Care for Burns
Can wait until patent airway, adequate circulation, and fluid replacement is in place
Cleansing and debridement
o Can be done in tank, shower, or bed
o Debridement may be done in surgery (loose necrotic skin is removed)
o Bath given with surgical detergent, disinfectant, or cleansing agent to reduce pathogenic organisms (ex:
Clorox)
Infection is the most serious threat to further tissue injury and possible sepsis
Survival is related to prevention of wound contamination
o Source of infection is pts own flora, predominantly from the skin, resp. tract, and GI tract
o Prevention of cross contamination from other pts is the priority for nurses
2 methods used to control infections
o Open method- pts burn is covered with a topical antibiotic and has no dressing
o Closed method- uses sterile gauze impregnated with or laid over a topical antibiotic; dressing changed 2-3
times q 24 hrs
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Staff should wear disposable hats, gowns, gloves, masks when wounds are exposed
Appropriate use of sterile vs. nonsterile techniques
Keep room warm
Careful hand washing
Any bathing areas disinfected before and after bathing
Coverage is the primary goal for burn wounds
Since there is usually not enough unburned skin for immediate skin grafting other temporary wound closure
methods are used:
o Allograph or homograft same species which is usually from cadavers; used for wound closure (temporary 3
days-2 weeks
o Porcine skin- heterograft or xenograft- different species; temporary 3 days to 2 weeks
o Autograft or cultured epithelial autograft- pts own skin cells (permanent)
Surgeons agree that no single product or technique is right for every burn situation
So far theres no true replacement for healthy, intact skin (not only a physical barrier but it also controls temp
through adjustment of blood flow and evaporation of sweat)
Face is vascular and subject to increased edema so use open method if possible to decrease confusion and
disorientation
Eye care- use saline rinses, artificial tears
Hands and arms- extended and elevated on pillow or in slings to minimize edema, may need splints to keep
them in functional positions
Ears- keep free of pressure; ear burns- no pillows
Neck burns- should not use pillows in order to decrease wound contraction
Perineum- must be kept clean and dry; indwelling foley will help in this and also to provide hourly outputs
Lab tests PRN to monitor electrolyte imbalance and ABGs
Physical therapy started immediately
Medications
Pain control
o IV administered narcotics such has morphine (drug of choice), hydromorphone, or fentanyl are the best means
of managing pain
o Avoid PO, SQ, and IM routes of administration until hemodynamic stability and unimpaired tissue perfusion
return
o As the pt enter the rehabilitative stage of care alternative therapies for pain control are added, like: distraction,
self-hypnosis, guided imagery, and relaxation techniques
o IV pain meds initially due to:
GI fxn is slowed or impaired b/c of shock or paralytic ileus
IM injections will not be absorbed well
Antimicrobial Agents
o To eliminate infection on the surface of the burn wound, topical antimicrobial therapy is used, depending on
protocol
o They are not applied until the pt is admitted to a burn unit
o 3 agents used to most: mafenide acetate (sulfamylon) cream, silver natrate 0.5% soaks, and sulfadiazine
(silvadene) cream (drug of choice)
Tetanus prophylaxis
o If the pts immunization status is in doubt, tetanus toxoid is administered IM early in the acute phase of care
o Given routinely to all burn pts b/c of the likelihood of anaerobic burn-wound contamination
Preventing Gastric Hyperacidity
o Hyperacidity must be controlled to prevent Curlings ulcer
o To control gastric acid secretion during the acute phase histamine H2 blockers or proton pump inhibitors can
be administered IV
Treatments
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Surgery- 3 types (escharotomy, surgical debridement, and autografting)


o Escharotomy
when the burn eschar forms circumferentially around the torso or extremities, it acts as a tourniquet,
impairing circulation; if not fixed the body part can become gangrenous
a surgical incision is made longitudinally along to extremity or the trunk to release taut skin and allow for
expansion caused by edema formation
o Surgical Debridement
The process of excising the wound to the level of fascia or sequentially removing thin slices of the burn
wound to the level of viable tissue
o Autografting
Used to effect permanent skin coverage
Skin is removed from healthy tissue (donor site) of the burn-injured pt and applied to the wound
Biologic and biosynthetic dressings
o Refer to any temporary material that rapidly adheres to the wound bed, promotes healing, and/or prepares the
burn wound for permanent autograft coverage
o Types of dressings:
Homograft or allograft- human skin that has been harvested from cadavers
Heterograft or xenograft- skin obtained from an animal usually a pig
Wound management
o Outcomes of care depend on the prevention and treatment of infection through daily topical wound care,
wound monitoring, and wound excision and closure
o Goals of wound management:
Control microbial colonization and prevent wound infection
Prevent wound progression
Achieve wound coverage as early as possible
Promote fxn of healing skin
o Debriding the wound
Necrotic tissue that remains despite phagocytic action retards healing and prolongs inflammation
Debridement- the process of removing all loose tissue, wound debris, and eschar from the wound
Dressing the wound
o Open and closed methods (discussed earlier)
o Positioning, splints and exercise
Early physical therapy includes maintaining antideformity positions
Splints immobilize body parts and prevent contractures of the joints (applied ASAP after surgery)
In early acute phase the physical therapist prescribes active and passive ROM exercises performed every
2 hrs at the bedside
o Support garments- apply uniform pressure to prevent or reduce hypertrophic scarring; wear for 6 months to 1
year after surgery
Nutritional Therapy
o Fluid replacement takes priority over nutritional needs in the initial emergent phase b/c of decreased
peristalsis
o NG tube is inserted and connected to low intermittent suction for decompression
o when bowel sounds return (48-72 hrs) after injury, start with clear liquids and regress to a diet high in proteins
and calories
o burn pts need more calories and failure to provide will lead to delayed wound healing and malnutrition
o give calorie containing liquids instead of water due to need for calories and potential for water intoxication
o enteral feedings into the duodenum (recommended) can reduce N & V and increase wound healing
Special Needs of the Nursing Staff
the staff of burn units are prone to higher rates of burn-out
the care of burn pts is a long journey that the pt, nurse, and significant others must travel
the road to recovery is full of potential threats to the pt
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support services are necessary for the medical team of any long-term burn pts
Burns (scenario)
Bernie has been in a fire and he is wrapped up like a mummy. Bernie BURNS will help learn burn care
B=breathing- keep airway open; facial burns, signed nasal hair, hoarseness, sooty sputum,, bloody sputum and
labored respirations indicate trouble
B=body image- assist Bernie in coping by encouraging expression of thoughts and feelings
U=urine output- in an adult, urine output should be 30-70 cc/hr; watch K+ to keep it btw. 3.5-5.0 mEq/L
R=resuscitation of fluid- salt & electrolyte solutions are essential over the 1 st 24 hrs
o Maintain BP at 90-100 systolic
o of the fluid for the 1st 24 hrs should be administered over the 1st 8 hrs and the rest is administered over the
next 16 hrs
o First 24 hr calculation starts at the time of injury
R=rule of nines- used for adults to determine burn surface area
N=nutrition- protein & calories are components of the diet
o Supplemental gastric tube feedings or hyperalimentation may be used in pts with large burned areas
o Daily weights will assist in evaluating the nutritional needs
S=shock- watch the BP and renal fxn
S=Silvadene- for infections
Other Factors to consider
Full thickness burns and deep partial thickness burns are initially anesthetic b/c nerve endings are destroyed
Superficial to moderate partial thickness burns are very painful b/c they dont kill the nerve endings
Severe dehydration is possible even though the pt maybe edematous b/c there are no fluids in the vascular space
circulating in the body
Shivering due to chilling caused by heat loss, anxiety, and pain
Unable to recall events RT hypoxia associated with smoke inhalation, or head trauma or overdose of sedatives or
pain meds

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