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Burns
Burns 150 150 Tony Guo

Burns

  • Occur when there is injury to tissues of body caused by heat, chemicals, electrical current, or radiation
  • Should be viewed as preventable

Types of burn injury

  • Thermal burns
    • Caused by lame, lash, scald, or contact with hot objects
  • Chemical burns
    • Contact with acids, alkalis, and organic compounds
    • Alkali burns (from cement, oven and drain cleaners, and heavy industrial cleansers) can be more difficult to manage than acid burns (from hydrochloric, oxalic, and hydrofluoric acid), since alkalis adhere to tissue, causing protein hydrolysis and liquefaction.
  • Smoke inhalation injury
    • From breathing noxious chemicals or hot air can cause damage to the respiratory tract.
    • Three types of smoke and inhalation injuries can occur:
      • Metabolic asphyxiation
        • Inhaling certain smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide
        • Increasing carboxyhemoglobin blood levels by 20% leading to death
      • Upper airway injury
        • Inhalation injury to the mouth, oropharynx, and/or larynx
      • Lower airway injury.
        • Injury to the trachea, bronchioles, and alveoli
  • Electrical burns
    • Intense heat generated from an electric current such that direct damage to nerves and vessels, causing tissue anoxia and death,
  • Cold thermal injury
    • Frostbite
Skin Cancer : Nursing Management
Skin Cancer : Nursing Management 150 150 Tony Guo

Nursing Management

  • Prevention of spread
  • Prevention of secondary infections
  • Specific skin care
    • Wet compresses
    • Baths
    • Topical medications
  • Control of pruritus
    • Break the itch/scratch cycle
    • Cool environment
    • Hydration, wet compresses, moisturizers
    • Topical drugs
  • Cosmetic procedures
    • Topical procedures
    • Injection
    • Elective surgery
      • Laser surgery
      • Face lift
      • Liposuction

Nursing management

  • Preoperative management
    • Informed consent
    • Patient teaching
  • Postoperative management
    • Pain management
    • Monitor for signs of infection and adequate circulation
Skin Cancer : Non-melanoma Skin cancers
Skin Cancer : Non-melanoma Skin cancers 150 150 Tony Guo

Non-melanoma Skin cancers

  • Actinic keratosis
    • Premalignant skin lesions
  • Basal cell carcinoma
    • Most common type of skin cancer
    • Least deadly
  • Squamous cell carcinoma
    • Potential to metastasize
    • Pipe, cigar, and cigarette smoking
    • Immunosuppression leads to a dramatic increase in the incidence

Malignant melanoma

  • Cause unknown
    • Environmental factors
    • Genetic factors
  • Risk factors
    • Red or blonde hair
    • Light-colored eyes
    • Fair skin that freckles
    • Chronic sun exposure
    • Family history
  • ABCDE Rule
    • Asymmetry
    • Border irregularity
    • Color change
    • Diameter >6 mm
    • Evolving in appearance
  • Interprofessional Care
    • Treatment determined by
    • Site of original tumor
    • Stage of the cancer
    • Patient’s age and general health
    • Includes wide surgical incision and adjuvant therapy
  • Tumor staging
    • O to IV
    • Based on tumor size, nodal  involvement, and  metastasis

Diagnostic and surgical therapy

  • Skin scraping
    • Obtain a sample of surface cells (stratum corneum) for microscopic inspection and diagnosis
  • Electrodessication/Electrocoagulation
    • The heat created from electrical energy, burns and destroys tissue
  • Curettage
    • The removal and scooping away of tissue using an instrument called a curette
  • Punch biopsy
    • To obtain a tissue sample for histologic study or to remove small lesions
  • Cryosurgery
    • Destroying epidermal lesions by using subfreezing temperature
  • Excision—Mohs procedure
Skin Cancer : Assessment abnormalities
Skin Cancer : Assessment abnormalities 150 150 Tony Guo

Assessment abnormalities

Alopecia

Loss of hair (localized or general)

Heredity, friction, rubbing, traction, trauma, stress, infection, inflammation, chemotherapy, pregnancy, emotional shock, tinea capitis, immunologic factors

Angioma

Tumor consisting of blood or lymph vessels

Normal increase in incidence with aging, liver disease, pregnancy, varicose veins

Carotenemia (carotenosis)

Yellow discoloration of skin, no yellowing of sclerae, most noticeable on palms and soles

Vegetables containing carotene (e.g., carrots, squash), hypothyroidism

Comedo (acne lesion)

Enlarged hair follicle plugged with sebum, bacteria, and skin cells; can be open (blackhead) or closed (whitehead)

Heredity, certain drugs, hormonal changes with puberty and pregnancy

Cyanosis

Slightly bluish gray or dark purple discoloration of the skin and mucous membranes caused by excessive amounts of reduced hemoglobin in capillaries

Cardiorespiratory problems, vasoconstriction, asphyxiation, anemia, leukemia, and malignancies

Cyst

Sac containing fluid or semisolid material

Obstruction of a duct or gland, parasitic infection

Ecchymosis

Large, bruise-like lesion caused by collection of extravascular blood in dermis and subcutaneous tissue

Trauma, bleeding disorders

Erythema

Redness occurring in patches of variable size and shape

Heat, certain drugs, alcohol, ultraviolet rays, any problem that causes dilation of blood vessels in the skin

Hematoma

Extravasation of blood of sufficient size to cause visible swelling

Trauma, bleeding disorders

Hirsutism

Male distribution of hair in women

Abnormality of ovaries or adrenal glands, decrease in estrogen level, familial trait

Hypopigmentation

Loss of pigmentation resulting in lighter patches than the normal skin

Chemical agents, nutritional factors, burns, inflammation, infection

Intertrigo

Dermatitis of overlying surfaces of the skin

Moisture, irritation, obesity; may be complicated by Candida infection

Jaundice

Yellow (in white patients) or yellowish brown (in African Americans) discoloration of the skin, best observed in the sclera, secondary to increased bilirubin in the blood

Liver disease, red blood cell hemolysis, pancreatic cancer, common bile duct obstruction

Keloid

Hypertrophied scar beyond wound margins

Predisposition more common in African Americans

Lichenification

Thickening of the skin with accentuated normal skin markings

Repeated scratching, rubbing, and irritation usually as a result of pruritus or neurosis

Mole (nevus)

Benign overgrowth of melanocytes

Defects of development; excessive numbers and large, irregular moles; often familial

Petechiae

Pinpoint, discrete deposits of blood <1-2 mm in the extravascular tissues and visible through the skin or mucous membrane

Inflammation, marked vasodilation, blood vessel trauma, blood dyscrasia that results in bleeding tendencies (e.g., thrombocytopenia)

Telangiectasia

Visibly dilated, superficial, cutaneous small blood vessels, commonly found on face and thighs

Aging, acne, sun exposure, alcohol, liver failure, corticosteroids, radiation, certain systemic diseases, skin tumors

Tenting

Failure of skin to return immediately to normal position after gentle pinching

Aging, dehydration, cachexia

Varicosity

Increased prominence of superficial veins

Interruption of venous return (e.g., from tumor, incompetent valves, inflammation), commonly found on lower legs with aging

Vitiligo

Complete absence of melanin (pigment) resulting in chalky white patch

Autoimmune, familial, thyroid disease

Skin Cancer : Health promotion
Skin Cancer : Health promotion 150 150 Tony Guo

Health promotion

    • Avoiding environmental hazards
    • Adequate hygiene and good nutrition
    • Skin self-examination
    • Periodic professional exams for areas difficult to see
  • Environmental Hazards
    • Sun exposure
      • Ultraviolet (UV) rays-
        • UVA- tanning
        • UVB- sunburn
      • Other factors include high altitude, being in snow, and tanning booths
      • Sun safety
    • Irritants and allergens
    • Radiation
  • Sleep
    • Adequate rest increases the patient’s ability to tolerate itching, thereby decreasing skin damage from the resultant scratching
  • Exercise
    • Increases circulation and dilates the blood vessels
    • It’s psychologic effects can improve one’s appearance and mental outlook
  • Hygiene
    • The normal acidity of the skin and perspiration protect against bacterial overgrowth.
    • Most soaps are alkaline and neutralize the skin surface, leading to a loss of protection.
    • Skin and hair must be washed often enough to remove excess oil and excretions and to prevent odor.
    • Older persons should avoid harsh soaps and shampoos and frequent bathing because of the dryness of their skin and scalp.
  • Nutrition
    • Vitamin A: necessary for normal wound healing
    • Vitamin B complex: Essential for complex metabolic functions. Deficiencies of niacin and pyridoxine (B6) manifest as dermatologic symptoms such as erythema, bullae, and seborrhea-like lesions
    • Vitamin C: Essential for connective tissue formation and normal wound healing. Absence of vitamin C causes symptoms of scurvy such as bleeding gums
    • Vitamin D3: Essential for bone health
    • Vitamin K: Essential for synthesizing blood clotting factors
Skin Cancer and Other Skin Problems
Skin Cancer and Other Skin Problems 150 150 Tony Guo

Skin Cancer and Other Skin Problems

Lesion distribution terminology

  • Annular – Circular, begins in center and spreads to periphery (e.g., tinea corporis [ringworm])
  • Asymmetric – Unilateral distribution
  • Confluent – Merging together (e.g., urticaria [hives])
  • Discrete – Distinct individual lesions that remain separate (e.g., acne)
  • Gyrate – Twisted, coiled spiral, snakelike
  • Grouped – Clusters of lesions (e.g., vesicles of contact dermatitis)
  • Localized – Limited areas of involvement that are clearly defined (confined to one area)
  • Polycyclic – Annular lesions grow together (e.g., psoriasis)
  • Solitary – Single lesion
  • Symmetric – Bilateral distribution
  • Zosteriform – Linear arrangement along a dermatome area (e.g., herpes zoster)

Assessment variation in light and dark-skinned person

Condition

Light skin

Dark skin

Cyanosis

Grayish blue tone, especially in nail beds, earlobes, lips, mucous membranes, palms, and soles

Ashen or gray color most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds

Ecchymosis

Dark red, purple, yellow, or green color, depending on age of bruise

Purple to brownish black. Difficult to see unless occurring in an area of light pigmentation

Erythema

Reddish tone, possibly accompanied by increased skin temperature secondary to localized inflammation

Deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation

Jaundice

Yellowish color of skin, sclera, fingernails, palms, and oral mucosa

Yellowish green color most obviously seen in sclera of eye (do not confuse with yellow eye pigmentation, which may be evident in dark-skinned patients), palms, and soles

Pallor

Pale skin color that may appear white or ashen; also evident on lips, nail beds, and mucous membranes

Lack of underlying red tone in brown or black skin. In light-skinned African Americans, yellowish brown skin. In dark-skinned African Americans, ashen or gray skin

Petechiae

Lesions appearing as small, reddish purple pinpoints, best observed on abdomen and buttocks

Difficult to see. May be evident in the buccal mucosa of the mouth or conjunctiva of the eye

Rash

May be visualized and felt with light palpation

Not easily visualized, but may be felt with light palpation

Scar

Generally heals, showing narrow scar line

Higher incidence of keloid development, resulting in a thickened, raised scar

Nonverbal Aids : Verbal Aids : Hearing
Nonverbal Aids : Verbal Aids : Hearing 150 150 Tony Guo

 

Nonverbal Aids

Verbal Aids

Draw attention with hand movements.

Speak normally and slowly.

Have speaker’s face in good light.

Do not overexaggerate facial expressions.

Avoid covering mouth or face with hands.

Do not overenunciate.

Avoid chewing, eating, smoking while talking.

Use simple sentences.

Maintain eye contact.

Rephrase sentence. Use different words.

Avoid distracting environments.

Write name or difficult words.

Avoid careless expression that the patient may misinterpret.

Do not shout.

Use touch.

Speak in normal voice directly into better ear.

Move close to better ear.

Avoid light behind speaker.

Otosclerosis

  • The most common cause of bilateral hearing loss in young adults
    • Tympanum takes on a reddish blush (Schwartz’s sign)
    • Poor air conduction
    • Treated with medications that slow bone resorption, hearing aids, and surgery

Presbycusis

  • Hearing loss associated with aging

Type

Hearing change and prognosis

Sensory

Atrophy of auditory nerve, Loss of sensory hair cells

Loss of high-pitched sounds. Little effect on speech understanding.

Good response to sound amplification

Neural

Degenerative changes in cochlea and spinal ganglion

Loss of speech discrimination.

Amplified alone not sufficient

Metabolic

Atrophy of blood vessels in wall of cochlea with interruption of essential nutrient supply

Uniform loss for all frequencies accompanied by recruitment.

Good response to hearing aid

Cochlear

Stiffening of basilar membrane, which interferes with sound transmission in the cochlea

Hearing loss increases from low to high frequencies. Speech discrimination affected with higher-frequency loss. Helped by appropriate forms of amplification

Interprofessional Management : Hearing
Interprofessional Management : Hearing 150 150 Tony Guo

Interprofessional Management

Nursing Assessment

  • Health Promotion
    • Ototoxic substances—drugs
    • Ototoxic substances—industrial chemicals
      • Toluene, carbon disulfide, mercury
    • Monitoring is important
    • Discontinuing drug may be indicated
  • Assistive devices and techniques
    • Hearing aids
      • Fit by a specialist
      • Provide amplification, sound lateralization, speech discrimination
      • Require a motivated, capable user for optimum success
    • Speech reading
      • Lip reading
      • Visual cues associated with speech facilitates understanding for 40% of
        spoken words
    • Sign language
      • For those with profound impairment
      • Sign language is not universal
      • American sign language (ASL) is used in the United States and in English-speaking areas of Canada
    • Amplification devices
    • Alerting systems
    • Texting systems
    • Closed caption
    • Specially trained dogs
  • Implantable hearing device or aid
    • Fully implantable
      • Nothing externally visible
    • Partially implantable
      • Have an external component worn behind or in the ear
  • Cochlear implant
    • For severe to profound sensorineural hearing loss in one or both ears
    • Ideal candidates became deaf after acquiring speech and language
    • Provides sound
    • Improves lip-reading ability
    • Enables monitoring own speech volume
    • Decreases feelings of isolation
Classifications of hearing loss
Classifications of hearing loss 150 150 Tony Guo

Classifications of hearing loss

Decibel (dB) loss

0-15

Normal hearing

16-25

Slight hearing loss

26-40

Mild impairment

41-55

Moderate impairment

56-70

Moderately severe impairment

71-90

Severe impairment

>90

Profound deafness*

Clinical manifestations

  • Early signs of hearing loss often go unnoticed by patient
  • Pressure by others is a significant factor in whether help is sought
  • The unseen handicap
  • Understanding should be validated in patient teaching interactions
  • Obtain interpreter assistance
  • Ineffective communication and interaction can be frustrating for both patient and caregiver(s)
    • Withdrawal, suspicion, loss of self-esteem and insecurity are common psycho-emotional complications with advancing hearing loss
Types of hearing loss
Types of hearing loss 150 150 Tony Guo

Types of hearing loss

  • Conductive hearing loss 
    • Sound transmission to inner ear impaired
      • Patients actually hear better in noisy environments
      • Patient often speaks softly
      • Identify and treat cause
      • Suggest hearing aid
    • Caused by 
      • Otitis media with effusion
      • Impacted cerumen
      • Perforation of TM
      • Otosclerosis
      • Narrowing of the external auditory canal
  • Sensorineural hearing loss  
    • Results in ability to hear sound but  inability to understand speech
      • Can lead to misunderstanding by others 
      • Hearing aids make sounds louder but not clearer
    • Caused by
      • Impairment of the inner ear
      • Vestibulocochlear nerve (CN VIII) damage
      • Congenital and hereditary factors
      • Noise trauma
      • Aging (presbycusis)
      • Meniere’s disease
    • Ototoxic drugs
      • Aspirin
      • NSAIDs
      • Antibiotics
      • Loop diuretics
      • Chemotherapy drugs
  • Mixed hearing loss
    • Central and functional hearing loss
      • Deafness in other family members often present
      • Can be psychologically or emotionally related
  • Sudden hearing loss
    • Sudden deafness
      • Unexplained, rapid loss of hearing
      • Usually affects just one ear
      • Medical emergency
  • Tinnitus
    • Perception of noise without an actual source of sound
    • “Ringing in the ears”
    • May be first symptom of hearing loss
      • Most commonly caused by noise
      • More than 200 drugs cause tinnitus