Exam 1

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 client’s 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 one’s 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

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 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 person’s 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 2

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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. 3

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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 4

 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 5

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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  Physician’s 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 6

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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

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hemorrhage o excessive blood loss o a concealed is internally from blood vessel that’s 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

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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

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 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 9

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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) 10

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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 drug’s 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. 11

 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 drug’s 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:

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drug dependence- a person’s 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 body’s 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

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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 client’s 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 client’s 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 client’s 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 nurse’s 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)  Client’s 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  MAR’s (medication administration records) vary in form, but all include the client’s 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 client’s 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

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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 client’s 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 physician’s 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 client’s medication (including prescriptions, vitamins, supplements, and over-the-counter) on admission  Medication Dispensing Systems  

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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 client’s 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

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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

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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 ½ to 2 inches; length is chosen according to the client’s muscle development, the client’s 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 client’s 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 1½ 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 

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Dorsogluteal site- don’t give in children under 3 unless the child has been waking for at least 1 yr; make sure you don’t hit the sciatic nerve Deltoid site- don’t 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 individual’s 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  Client’s 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 client’s 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 client’s 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 client’s life  Degree of risk- is affective by the client’s 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 infant’s 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

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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

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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 provider’s orders or institutional policies and procedures  Prepare the surgical site and surrounding area with antimicrobial agent when indicated  Document surgical skin preparation in the client’s 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 body’s 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 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

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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

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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 ½ 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

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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

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 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

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 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

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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 client’s 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 client’s 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

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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 

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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

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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

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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 pt’s 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  

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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 Pt’s with >20% TBSA experience decreased peristalsis with resultant gastric distention and increased risk of aspiration o Stress ulcers (Curling’s 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 body’s 1st line of defense - partial thickness wounds can convert to full-thickness wounds with infection present - pt may get sepsis from wound infections 

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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 pt’s 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 pt’s 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 pt’s 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 ABC’s  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 pt’s 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 pt’s progress and to modify intervention strategies:

o o o

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

o

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

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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 pt’s 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- pt’s 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 43

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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- pt’s own skin cells (permanent)  Surgeons agree that no single product or technique is right for every burn situation  So far there’s 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 pt’s 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 Curling’s ulcer o To control gastric acid secretion during the acute phase histamine H2 blockers or proton pump inhibitors can be administered IV  Treatments 44

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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 45

 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 ½ 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 nine’s- 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 don’t 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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