NNNN
NSG233 Medical Surgical Nursing Exam 4 Study Guide
Modules 10,11,12
Module 10: Nursing Care of Patients with Disorders of the Integumentary System
Burns:
• Treatment:
o Fluid resuscitation o Nutrition o Surgical debridement o Determine wound
coverage on Antimicrobial therapies
• Incidence
o Men 20s-
30s more
likely to
report
burns
o Home
burns
more
likely
• Gerontologic Considerations
Postural stability
Strength
Coordination
Sensation
Visual acuity
Declining memory
• Complications associated with burns o Pneumonia (most common)
o UTIs
o Respiratory failure
o Septicemia o Cellulitis O Wound infection o Kidney injury
o Arrhythmias
o HAI (Central lines infection)
• Prevention
o Education on home setÝngs
• Severity
o Age of patient
Young children and older adults increase morbidity and mortality
• Depth of burn determined by:
o Negative nikolsky’s sign: epidermis is intact, if rubbed the burn tissue does not
separate from the underlying dermis
1
, lOMoARcPSD| 46240884
NSG233 Medical Surgical Nursing Exam 4 Study Guide Modules 10,11,12
o First defree (surface only): affect only the epidermis, or outer layer of skin. The burn
site is red, painful, dry, and with no blisters.
o Second degree (partial thickness): entire epidermis and varying portions of the
dermis (blister formation). Hair follicles and skin appendages remain intact
o Third degree (full thickness): total destruction of the epidermis and dermis, In some
cases the underlying tissue. Wound color ranges widely from pale white to red,
brown or charred. Nerve fibers are damaged. Skin appeared leathery and dry
o Fourth degree (deep burn necrosis): extend into deep tissue, muscle or bone
• Factors that are considered to determine depth:
o How injury occurred o Causative agent
o Temperature
o Duration of contract with causative agent o Thickness of skin at injury site
• Amount of TBSA
• Presence of inhalation injury
• Presence of other injuries
2
, NNNN
NSG233 Medical Surgical Nursing Exam 4 Study Guide
Modules 10,11,12
• Location of injury
• Presence of comorbid complications
• Methods to estimate TBSA
o Rule of nines- anatomic regions, each representing 9%
o Lund and Browder- more precise, used on pediatrics
o Palmer- scattered burns, very large burns with minimal sparing, determine extent of
injury
Local and systemic effects of burns:
• Pathophysiology
o Tissue destruction through coagulation, protein denaturation, ionization of cellular
contents
• Zones of injury
o Coagulation: innermost area where cellular death occurs
o Stasis: middle area has compromised blood supply inflammation and tissue injury o
Hyperemia: the outermost area, sustains the least damage
• Cardiac Alterations o Decrease CO, loss of plasma volume o Increase capillary
permeability
o Increase pulse
o Increase workload of heart and oxygen demand o Hypovolemia (early burn shock)
o First 24-36 hrs after burn injury = greatest volume of fluid shift
3
, lOMoARcPSD| 46240884
NSG233 Medical Surgical Nursing Exam 4 Study Guide Modules 10,11,12
• Fluid and electrolytes alterations o Edema forms rapidly (escharotomy to treat edema
or fasciotomy) o Emergent/resuscitative phase: monitor circulation closely, potential
for acute compartment syndrome
o Acute/intermediate phase: monitor for development of VTE
o Hyperkalemia expected after
IMMEDIATELY burn
o Hypokalemia expected later on after
burn due to fluid shift
o Hyponatremia present from plasma
loss in the first week
o Hematocrit may be
elevated
o Abnormalities in coagulation, decrease in
platelets (thrombocytopenia), prolonged
clotÝng and pTT
• Pulmonary Alterations
Singed facial hair, Shortness of breath, hoarseness, difficulty speaking
o S/S of inhalation injury
Carbonaceous sputum (sputum with carbon particles which appears to be
black; soot)
o Bronchoscopy is standard test for definitive diagnosis
o Expectoration of carbon particles in sputum is cardinal sign of lower airway
inhalation injury
o Treatment to CO poisoning is 100% oxygen administration
4
NSG233 Medical Surgical Nursing Exam 4 Study Guide
Modules 10,11,12
Module 10: Nursing Care of Patients with Disorders of the Integumentary System
Burns:
• Treatment:
o Fluid resuscitation o Nutrition o Surgical debridement o Determine wound
coverage on Antimicrobial therapies
• Incidence
o Men 20s-
30s more
likely to
report
burns
o Home
burns
more
likely
• Gerontologic Considerations
Postural stability
Strength
Coordination
Sensation
Visual acuity
Declining memory
• Complications associated with burns o Pneumonia (most common)
o UTIs
o Respiratory failure
o Septicemia o Cellulitis O Wound infection o Kidney injury
o Arrhythmias
o HAI (Central lines infection)
• Prevention
o Education on home setÝngs
• Severity
o Age of patient
Young children and older adults increase morbidity and mortality
• Depth of burn determined by:
o Negative nikolsky’s sign: epidermis is intact, if rubbed the burn tissue does not
separate from the underlying dermis
1
, lOMoARcPSD| 46240884
NSG233 Medical Surgical Nursing Exam 4 Study Guide Modules 10,11,12
o First defree (surface only): affect only the epidermis, or outer layer of skin. The burn
site is red, painful, dry, and with no blisters.
o Second degree (partial thickness): entire epidermis and varying portions of the
dermis (blister formation). Hair follicles and skin appendages remain intact
o Third degree (full thickness): total destruction of the epidermis and dermis, In some
cases the underlying tissue. Wound color ranges widely from pale white to red,
brown or charred. Nerve fibers are damaged. Skin appeared leathery and dry
o Fourth degree (deep burn necrosis): extend into deep tissue, muscle or bone
• Factors that are considered to determine depth:
o How injury occurred o Causative agent
o Temperature
o Duration of contract with causative agent o Thickness of skin at injury site
• Amount of TBSA
• Presence of inhalation injury
• Presence of other injuries
2
, NNNN
NSG233 Medical Surgical Nursing Exam 4 Study Guide
Modules 10,11,12
• Location of injury
• Presence of comorbid complications
• Methods to estimate TBSA
o Rule of nines- anatomic regions, each representing 9%
o Lund and Browder- more precise, used on pediatrics
o Palmer- scattered burns, very large burns with minimal sparing, determine extent of
injury
Local and systemic effects of burns:
• Pathophysiology
o Tissue destruction through coagulation, protein denaturation, ionization of cellular
contents
• Zones of injury
o Coagulation: innermost area where cellular death occurs
o Stasis: middle area has compromised blood supply inflammation and tissue injury o
Hyperemia: the outermost area, sustains the least damage
• Cardiac Alterations o Decrease CO, loss of plasma volume o Increase capillary
permeability
o Increase pulse
o Increase workload of heart and oxygen demand o Hypovolemia (early burn shock)
o First 24-36 hrs after burn injury = greatest volume of fluid shift
3
, lOMoARcPSD| 46240884
NSG233 Medical Surgical Nursing Exam 4 Study Guide Modules 10,11,12
• Fluid and electrolytes alterations o Edema forms rapidly (escharotomy to treat edema
or fasciotomy) o Emergent/resuscitative phase: monitor circulation closely, potential
for acute compartment syndrome
o Acute/intermediate phase: monitor for development of VTE
o Hyperkalemia expected after
IMMEDIATELY burn
o Hypokalemia expected later on after
burn due to fluid shift
o Hyponatremia present from plasma
loss in the first week
o Hematocrit may be
elevated
o Abnormalities in coagulation, decrease in
platelets (thrombocytopenia), prolonged
clotÝng and pTT
• Pulmonary Alterations
Singed facial hair, Shortness of breath, hoarseness, difficulty speaking
o S/S of inhalation injury
Carbonaceous sputum (sputum with carbon particles which appears to be
black; soot)
o Bronchoscopy is standard test for definitive diagnosis
o Expectoration of carbon particles in sputum is cardinal sign of lower airway
inhalation injury
o Treatment to CO poisoning is 100% oxygen administration
4
