Adult Nursing Ppt

ADULT NURSING

Lecturer: Mr Steve Mohammed

Management of client’s - Burn Injury - Diabetes Mellitus

GROUP MEMBERSCHRISTAL PARIS - related causes, symptomsAARON WALLACE - phase of burn care,

psychological SUNITA RAMSARAN - common skin disordersANEESHA ALI GHANY - hyperglycemicAKEELA TRIM - diabetes mellitus Type 123

DEFINITION: A traumatic injury to skin or other organic tissue. Transfer of energy from a source to the body which inturn causes damage to the layers & structures of the skin, depending on severity muscle & bone (WHO, 2002).

ANATOMY OF THE SKIN

SEVERITY OF TISSUE DAMAGE DEPENDS

Temperature of insult Heat capacity Duration of contact Conductivity of tissues Skin composition

BURNS

Radiation Radiation

Chemical Chemical

ScaldScald

ElectricalElectrical

Contact Contact Fire Fire

TYPES OF BURNS

TYPES OF BURNS

TYPES OF BURNS

ASSESSMENT OF BURNS The rule of nine.

Lund – Browder method.

Palmer method.

RULE OF NINES An estimation of the TBSA involved in a burn is simplified

by using the rule of nines. The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces.

Wallace’s ‘Rule of Nines’.

LUND & BROWDER METHOD A more precise method.

Recognizes that the % of TBSA of various anatomic parts, especially the head and legs, & changes with growth.

Reliable estimate of the TBSA burned.

The initial evaluation is made on the patient’s arrival at the hospital & is revised on the 2nd & 3rd post-burn days.

PALMER METHOD In patients with scattered burns, a method to

estimate the percentage of burn is the palm method. The size of the patient’s palm is approximately 1% of TBSA.

PHASES OF BURN CARE Emergent Phase Begins with the burn injury, assessing

severity, initial care & ends when the patient is stable & begins to diurese & no longer requires fluid therapy.

Acute Phase Return of fluid from the cells (intracellular fluid) & between the cells (interstitial fluid) to the intravascular space & continuous care of the wounds to prevent infections & promote grafting & healing. (wks - mths).

Rehabilitation Phase Helping the patient return to previous or optiminal level of functioning. Many aspects of rehabilitation begins at the time of emergent care and continue through the phases.

NURSING INTERVENTIONS

Emergent phase Promoting Gas exchange & airway clearance.

Restoring fluid & electrolyte balance.

Maintaining normal body temperature.

Minimizing pain & anxiety.

Monitoring & managing potential complications.

Acute phase Restoring normal fluid balance. Preventing infection. Maintaining adequate nutrition. Promoting skin integrity. Relieving pain & discomfort. Promoting physical mobility. Strengthening coping strategies. Support patient & family processes. Monitoring & managing potential complications.

Rehabilitation phase Promoting activity tolerance.

Improving Body image & self concept.

Monitoring & managing potential complications

Promoting home and community based care.

WOUND DEBRIDEMENT

WOUND DEBRIDEMENTAs debris accumulates on the wound surface, it can retard

keratinocyte migration, thus delaying the epithelialization process.

GOALS

- To remove tissue contaminated by bacteria & foreign bodies.

- To remove devitalized tissue or burn eschar in preparation for grafting & wound healing.

TYPES OF DEBRIDEMENT

SHARP/SURGICAL

Uses surgical tools such as curettes, scapels or scissors to cut away devitalized tissue quickly and efficiently.

AUTOLYTIC Uses occlusive dressing to provide moist wound bed cleaning via patients’ own phagocytic cells and proteolytic enzymes.

CHEMICAL Uses enzymatic agents to degrade and chemically digest necrotic tissue

MECHANICAL Uses methods such as wet- to-dressings, hydrotherapy, and irrigation to remove debris from the wound bed.

BIOLOGIC Uses fly maggots to liquefy ingest necrotic tissue, also produces a bactericidal effect.

Types of Skin Grafting

• Biologic dressings( homografts and hetergrafts)

• Biosynthetic and Synthetic dressings• Dermal Substitutes • Autografts Cultural epithelial autografts

Dermal Substitutes • Artificial skin (Integra) is the newest type of

dermal substitute.. This “neodermis” becomes a permanent structure.

AUTOGRAFTSAutografts are the ideal means of covering burn wounds because the grafts are the patient’s own skin and thus are not rejected by the patient’s immune system.

Commonly used for reconstructive surgery, months or years after the initial injury

Autographs

Homograft dressings• Homograft, or allograft, is

human skin that has been harvested from cadavers. The use of this dressing however:

• It usually has a short supply• Expense, and still pose

problems. • It is manufactured as strips cut

to the pattern of the burn and applied using sterile technique.

Under normal circumstances, a homograft is rejected within 14 to 21 days following application.

Heterograft dressingsHeterograft, or xenograft, is skin obtained from an animal, usually a pig. Fresh porcine heterograft is available at some centers, frozen heterograft is much more commonly used.

Has an enzymatic action from the wound. Frequent changes of the heterograft dressing are necessary. Because of the high infection rates associated with this dressing.

Biosynthetic and Synthetic Dressings

Currently the most widely used synthetic dressing is Biobrane, which is composed of a nylon, Silastic membrane combined with a collagen derivative.

The material is semitransparent and sterile. It has a indefinite shelf life and is less costly than homograft or pigskin.

Skin Graft Procedure

PSYCHOLOGICAL COSMETIC Dermatologists, reconstructive & cosmetic surgeons

within the specialty can improve the physical look & feel of the scar, which, in turn, often leads to an improvement in the person’s psychological state.

Scar repair is the primary resource dermatologists can offer.

Assistance with psychological issues (ability to recognize if referral to a psychologist or psychiatrist is necessary.

COMMON SKIN DISORDERECZEMA (atopic dermatitis)

- inflammation of the upper layers of the skin.

- itching & redness occurs.

- common in children however can occur at any age.

- it is chronic & tends to flare periodically & then subside.

- it may be accompanied by asthma/hay fever.

DIAGNOSTIC ASSESSMENT METHODS No lab test is needed.

Skin examination.

Medical health history.

Family health history. (allergies)

Patch testing or other tests to rule out other skin diseases or identify conditions that accompany eczema.

NON SURGICAL MANAGEMENT

Apply lightweight, non fibered cloth dressings ( such as sheeting) saturated in lukewarm water to lesions for 20 mins, 3-4 times per day during acute stage.

Tar bath for 15-20 mins. daily preferably in the evening. (to lessen severe itching)

Topical corticosteroids application.

the drug cyclosporine for people whose condition doesn't respond to other treatments.

SURGICAL MANAGEMENT

• Phototherapy (used for mild, moderate, or severe

cases of atopic dermatitis in adults. It is used only

for severe symptoms in children.)

• Skin Laser & Surgery treatment (remove scars)

• Cosmetic Surgery

TREATMENT METHODAimed at decreasing the occurrence & severity of the

condition.

- Topical cortisone.

- Antihistamines & sedatives to treat pruritus.

- Avoid sunlight, especially with light-sensitive eczema.

- Brief showers (cool/lukewarm) & skin gently patted dry.

- Moisturizing cream (odorless & colourless).

- Fingernails kept short.

EVIDENCE BASED RESEARCH

Psoriasis has a tendency to improve and then recur periodically throughout life (Champion et al., 1998).

COMMON SKIN DISORDERLUPUS

An autoimmune disease.

Immune system is functioning abnormally in which it attacks healthy tissues not foreign organisms.

Lesions that appear as raised red scaling plaques with follicular plugging & central atrophy. (coin like)

Appear anywhere on the body however usually erupt (face, scalps, ears, neck, arms or parts exposed to sunlight).

It can resolve completely or cause hyperpigmentation, atrophy & scarring.

Facial plaque sometimes assume the butterfly pattern.

Hair becomes brittle & may fall out in patches.

LUPUS ERYTHEMATOSUS

ASSESSMENT Diagnosis is difficult because signs & symptoms

vary considerably from person to person.

Signs & symptoms may vary over time & overlap with those of many other disorders.

No one test can diagnose lupus.

Combination of blood & urine tests, signs & symptoms, & physical examination leads to the diagnosis.

NON SURGICAL MANAGEMENT

Anti- inflammatories (corticosteroids & NSAIDS).

Topical corticosteroids may suppress skin lesions.

Joint protection & energy conservation.

Application of heat or cold to affected areas.

SURGICAL MANAGEMENT

Surgery isn't used to treat mild or moderate symptoms of lupus.

It may be considered for people who have permanent, life-threatening kidney damage.

NURSING INTERVENTIONS Balanced diet.

- Foods high in protein, vitamins, & iron help maintain optimum nutrition & prevent anemia.

- However, renal involvement may mandate a low sodium diet.

- Provide bland, cool foods if the patient has a sore mouth.

Rest

- Schedule diagnostic tests & procedures.

- Inform the patient that several blood samples are needed initially & periodically there after to monitor progress.

Comfort

- Heat pack for relieve of joint pain & stiffness.

- Encourage regular exercise to maintain full ROM to prevent contractures.

Promote self image.

- Techniques (hypo allergenic cosmetics).

- Refer to hairdresser’s who specializes in scalp disorders.

- Shaving products.

- Offer the patient encouragement & emotional support

- Thorough patient teaching.

TREATMENT METHODS Anti-inflammatory medications for joint pain and

stiffness.

Steroid creams for rashes.

Corticosteroids of varying doses to minimize the immune response.

Anti-malarial drugs for skin and joint problems.

EVIDENCE BASED RESEARCH

Management of the more chronic condition involves periodic monitoring & recognition of meaningful clinical changes requiring adjustments in therapy (Ruddy et al., 2001).

COMMON SKIN DISORDERPsoriasis

Is a non-contagious skin condition that produces plaques of thickened, scaling skin.

Dry scales are result of rapid proliferation of skin cells triggered by the release of inflammatory chemicals from abnormal blood lymphocytes.

Affects the skin of the elbows, knees, and scalp. Sometimes the entire body.

PSORIASIS

DIAGNOSIS METHODS Physical examination - presence of classic plaque

- type lesions (change histologically progressing from early to chronic plaques).

Signs of nail & scalp involvement.

Positive Family History.

ASSESSMENT METHODS Assessment of patients & relatives coping

strategies with the skin condition & appearance of “normal” skin & skin lesions.

Examine areas especially affected: elbows, knees, scalp, gluteal cleft, and all nails for smallpits.

NURSING INTERVENTIONS

Promote Understanding

- Explain with sensitivity that there is no cure and that life time management is necessary; the disease process can usually be controlled.

- Instruct patient that the condition is not infectious , is not a reflection of poor personal hygiene, and is not skin cancer.

Increase Skin Integrity

Instruct to avoid picking or scratching areas.

Encourage patient to prevent the skin from drying out.

Improving Self- Concept & Body Image.

Monitoring & Managing Complications.

Create an environment in which the patient feels comfortable discuss important quality- of-life issues related to psycho social & physical response to this chronic illness.

TREATMENT METHODS Skin creams & lotions that moisturize & prevent

dryness.

Sunscreens regularly to prevent sunburns & skin damage.

Mild bath soap that won't irritate skin.

Bath or shower in warm water.

Avoid certain fabrics (wool & synthetics) that can make skin itch. Switch to cotton clothing & bed sheets.

Since warm, dry air can make skin dry, keep the thermostat in your house down and use a humidifier.

To relieve itching, place a cool washcloth or some ice over the area that itches, rather than scratching. 

EVIDENCE BASED RESEARCH

Psoriasis has a tendency to improve and then recur periodically throughout life (Champion et al., 1998).

Light therapy may be another option for treatment of psoriasis. With this treatment, the affected skin is exposed to controlled forms of artificial sunlight, usually after using Psoralen, a light-sensitizing medicine. This is called "PUVA" treatment.

Type 1 Type 2 Type 3

KEY FEATURES OF TYPE 1 DIABETES

Usually occurs before age 30

Patient will require exogenous insulin and dietary management

Is an autoimmune disease

KEY FEATURES OF TYPE 2 DIABETES

Failure of insulin to push glucose from bloodstream into cells, either due to insulin resistance or a shortage of insulin. 

An elevation of fasting blood sugar levels to at least 125 mg/dL. 

A significant increase in risk of developing chronic diseases such as heart disease, cataracts, high blood pressure, and dementia. 

ASSESSMENT METHODS Two fasting plasma glucose tests above 126mg/dl

or with normal fasting glucose

Two blood glucose levels above 200mg/dl during a 2 hour glucose tolerance test

NURSING INTERVENTIONS

Administer insulin when required

Administer glucose solutions: dextrose & half-normal saline

Observe for signs of hypoglycemia

Perform finger stick glucose testing

Identify food preferences, including ethnic and cultural needs

TREATMENT METHODS Meal planning

Exercise

Insulin

Anti-diabetic agents

REHABILITATIVE METHODS

HOW INSULIN WORKS

KEY FEATURES OF TYPE 3 DIABETES

ASSESSMENT METHODS Blood test Brain imaging Physical & neurological exam CT scan Magnetic Resonance Imaging (MRI)

NURSING INTERVENTIONS

Maintain a safe environment Promote mobility Promote sleep Provide educational sessions for the patient and

caregiver Provide for medication reconciliation

TREATMENT METHODS Insulin sensitizers Therapy emphasized on maintaining a familiar

lifestyle Manage glucose, blood pressure and cholesterol

levels

REHABILITATIVE METHODS

Normal sleeping pattern

Proper diet

Exercise

Adhere to medication prescribed

KEY FEATURES OF TYPE 1 DIABETES

Usually occurs before age 30 Patient will require exogenous insulin and

dietary management Is an autoimmune disease

KEY FEATURES OF TYPE 2 DIABETES

Failure of insulin to push glucose from bloodstream into cells, either due to insulin resistance or a shortage of insulin. 

An elevation of fasting blood sugar levels to at least 125 mg/dL. 

A significant increase in risk of developing chronic diseases such as heart disease, cataracts, high blood pressure, and dementia. 

ASSESSMENT METHODSTwo fasting plasma glucose tests above

126mg/dl or with normal fasting glucoseTwo blood glucose levels above 200mg/dl

during a 2 hour glucose tolerance test

NURSING INTERVENTIONSAdminister insulin when requiredAdminister glucose solutions: dextrose

and half-normal salineObserve for signs of hypoglycemiaPerform finger stick glucose testingIdentify food preferences, including ethnic

and cultural needs

TREATMENT METHODMeal planning ExerciseInsulinAnti-diabetic agents

REHABILITATIVE METHODS

HOW INSULIN WORKS

KETOACIDOSIS (DKA)Diabetic ketoacidosis is the extreme consequence of severe insulin deficiency at the insulin sensitve tissue: adipose tissue, skeletal muscle and liver. This condition requires emergency treatment with insulin and intravenous fluids bio chemically. DKA is defined as an increase in the serum concentration of ketons greater than 5 meq/l a blood glucose level of greater than 250/ mgl a blood pH less than 7.2 and HCO3 is 18meq/l or less.

THE THREE MAINCLINICAL FEATURES OF DKA ARE:

HyperglycemiaHyperglycemiaDehydration and electrolyte lossDehydration and electrolyte lossAcidosis Acidosis

CLINICAL SIGNS AND SYMPTOMS

Hyperglycemia signs of DKAPolydipsia Polyurea Blurred vision,WeaknessHeadache

SIGNS AND SYMPTOMS

DIAGNOSIS /ASSESSMENT Blood glucose levels 300 to 800 mg/dl ( may be lower

or higher).Low serum bicarbonate level 0-15 mEq/l Low pH 6.8 to 7.3 Low PaCO2 10-30 mm Hg Sodium and potassium level may be low , normal, or

high depending on amount of water loss (dehydration) Elevated creatine, blood urea nitrogen (BUN) and

hematocrit values may be seen with dehydration

NURSING ASSESSMENT Assess vital signs (especially blood pressure and arterial blood

gases, breath sounds and mental status every hour and document finds

Documents the patient’s laboratory values and the frequent changes in fluids and medications that are prescribed and monitors the patient’s responses.

Monitor the electrocardiogram (ECG) for dysrhythmias indicating abnormal potassium level

Include neurologic status checks as part of the hourly assessment as cerebral edema can be a severe and sometimes fatal outcome.

MEDICAL TREATMENT METHODS

Treating hyperglycemia, management of DKA Restoring electrolytesRehydration Reversing Acidosis

HYPERGLYCEMIC HYPEROSMOLARNONKETOTIC SYNDROME

HHNS also called hyperosmolar coma, is an acute complication of diabetes mellitus (particularly types 2) characterized by hyperglycemia, dehydration and hyperosmolarity, but little or no ketosis. The basic biochemical defect is a lack of effective insulin(ie. insulin resistance)

CLINICAL FEATURES • Hypotention • Profound dehydration (dry mucous

membranes, poor skin turgor),• Tachycardia,and variable neurologic• signs (eg, alteration of sensorium,• seizures, hemiparesis).

DIAGNOSIS EVALUATION • Serum test for glucose and osmolality great

elevated blood glucose, electrolytes, BUN, complete blood count

• Serum test for urine ketone bodies if minimal or absent

• Serum test for sodium and potassium testing for elevated, depending on the degree of dehydration despite total body lost

• Test for Urine specific gravity if elevated because of dehydration

NURSING INTERVENTION • Monitor for vital signs and dehydration such

as poor turgor, reduced urine output, thirst and dry mucous membrane.

• Monitor glucose and electrolyte levels during I.V therapy

• Monitor hourly intake and urine specific gravity

Nursing Intervention • Monitor for shock : rapid thread pulse , cool

extremities and hypotension • Monitor respiration rate and breath sounds• Monitor blood glucose • Because of the older age of the patient with HHNS, close

monitoring of volume and electrolyte status is for prevention of fluid overload, heart failure, and cardiac dysrhythmias.

MEDICAL TREATMENT To rehydration the patient, this improves

the blood pressure, urine output, and circulation

Fluids and potassium intravenous High glucose level is treated with insulin 

CHARACTERISTICS DKA HHNS

Patients most commonlyaffected

Can occur in type 1 or type 2diabetes; more common in type 1

Can occur in type 1 or type 2patients; more common in type 2 diabetes

Precipitating event Omission of insulin; physiologicstress (infection, surgery,CVA, MI)

Physiologic stress (infection,surgery, CVA, MI)

Onset Rapid (24 hrs) Slower (over several days)

Blood glucose levels Usually 250 mg/dL(13.9 mmol/L)

Usually 600 mg/dL(33.3 mmol/L)

Arterial pH level 7.3 Normal

Serum and urine ketones

Present Absent

Serum osmolality 300–350 mOsm/L 350 mOsm/L

Plasma bicarbonate level

15 mEq/L Normal

BUN and creatinine levels

Elevated Elevated

Mortality rate 5% 10%–40%

Reference• Endocrine disorders. (2012). In Medical-

surgical nursing made incredibly easy! (3rd ed., pp. 548-554). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

• Nanda Nursing Interventions. (n.d.). Retrieved March 3, 2015, from http://nanda-nursinginterventions.blogspot.com/2011/05/nursing-intervention-for-diabetes.html

Reference American Diabetes Association. Standards of

medical care in diabetes -- 2013. Diabetes Care. 2013;36 Suppl 1:S11-S66

Brunner, L. (2008). Brunner & suddarth's textbook of medical-surgical nursing (10th ed.). Philadelphia: lippincott williams & wilkins. Nettina, S. (2006).

Lippincott manual of nursing practice handbook (3rd ed.). Philadelphia: lippincott williams & wilkins.

REFERENCE http://hospitals.unm.edu/burn/classification.shtml

https://healthsciences.ucsd.edu/som/surgery/divisions/trauma-burn/about/burn-center/Documents/04%20The%20Skin_Burn%20Wounds_Treatment.pdf

http://www.zeemedical.com/pages/burn-classification

http://intranet.tdmu.edu.ua/data/kafedra/internal/distance/classes_stud/English/1course/Professional%20Nursing%20Role%20Transition%20Practicum/35.%20Practice%20nursing%20care%20for%20Clients%20with%20Burns.htm

http://www.woundsinternational.com/media/issues/284/files/content_8833.pdf

Endocrine disorders. (2012). In Medical-surgical nursing made incredibly easy! (3rd ed., pp. 548-554). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Nanda Nursing Interventions. (n.d.). Retrieved March 3, 2015, from http://nanda-nursinginterventions.blogspot.com/2011/05/nursing-intervention-for-diabetes.html

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