MedSurg: Integumentary, Vision, Hearing, Burns

What can a corneal abrasion lead to?

• If left untreated/worsens: corneal abrasion → corneal infection → corneal ulceration

• Acute emergency: infections that can permanently impair vision to develop rapidly

How do you assess corneal disorders?

• Pain

• Vision changes

• Secretions

• Photophobia

• Mechanism of injury (occupational or other exposure)

How do you medically diagnose a corneal disorder?

• Abrasion visible when viewed with a ‘slit lamp’

What planning/interventions can you do for corneal disorders?

• Eye drops: anti-infective and steroids

• Patient teaching: infection, administation of eye drops

What patient teaching can you provide for corneal disorders (infectious disorders of the eye)?

• Wash hands especially before and after touching infected eye or applying medication

• Avoid touching or rubbing your eyes, this can worsen the condition or spread it to your other eye

• Do not use the same eye drop dispenser/bottle for your infected and non-infected eyes

• Stop wearing contact lesnses until your eye doctor says it’s okay to start wearing them again

• Do not share personal items that may have come in contact with the eyes

What is the definition of retinal disorders (retinal holes, tears, and detachment)?

• Alteration in the continuity between the retina and the epithelium; may lead to blindness

How do you assess (risk factors and symptoms) of retinal disorders?

• Risk factors: trauma, age (shrinkage or vitreous gel), eye surgery

• Symptoms: flashes of light, “floaters”

What are interventions/planning for retinal disorders?

• Seek care immediately, as may be surgically cured

• Sometimes no treatment warranted

What are cataracts?

• Lens opacity

• Causes: aging due to loss of water of the lens and increased density, secondary to → DM, glaucoma, eye trauma, retinal detachment, chronic sun exposure

• Assessment: gradual loss of vision; no pain or eye redness; cloudy lens late in progression; progresses to blindness w/o surgery

• Surgical cure

How does glaucome develop?

• Forward displacment of iris → iris presses against cornea → reduction of outflow of aqueous humor → increased intraocular pressure (IOP) → irreversible damage to optic nerve due to tissue ischemia → blindness

• Risk factors: African Americans over age 40, anyone over age 60, family history of glaucoma

What is primary open-angle glaucoma?

• Angle between lens and cornea open → some movement of fluid to be reabsorbed

• Most common

• Assessment: early- no symptoms, gradual loss of vision (preipheral to central) and seeing halos around lights

What is primary angle-closure glaucoma?

• Angle between lens and cornea closed → no movement of fluid to be reabsorbed

• More severe

• Sudden onset, medical emergency

• Assessment: sudden sever pain around eyes, HA, brow pain, N/V, halos around lights, sudden blurred vision with decreased light perception

What are outcomes and pharamcologic treatment for glaucoma?

• Outcomes: consistent administration of drops, prevent progression

• Pharmacologic treatment: do not improve vision but prevent progression, multiple types of eye drops to decreases production of aqueous humor OR to increase reabsorption

What are surgical management and patient education regarding meds for glaucoma?

• Surgical management: multiple surgical approaches

• Patient education: MOA, administration, S/E, importance of timely dosing (every 12 hrs), avoid skipping doses, wait 5-10 min between medications to prevent dilution of the medications

What is latanoprost (Xalatan)?

• Class: prostaglandin agonsits

• MOA: reduce IOP, collects and drains aqueous humor faster

• Nursing implications: advise pt that eye color darkens and lashes elongate over time, use only in affected eye

What is timolol (Timoptic)?

• Class: Beta adrenergic blockers

• MOA: reduce IOP, limit production of aqueous humor and improves absorption

• Nursing implications: if also taking oral beta blockers monitor BP and HR due to additive systemic effects, if DM check glucose more often…may cause hypoglycemia or mask symptoms, do not take if asthma or COPD as they constrict pulmonary smooth muscles

How do you change in hospital nursing care for patients with impaired vision?

• Knock or announce yourself on entry

• Ensure all team members are aware of impaired vision

• Determine severity of impairment

• Orient the pt to the environment

• Ask the pt what assitance they prefer

• Do not move objects w/o the pt’s permission

• Remove obstacles and clutter

• Use normal tone of coice unless the pt is also hearing imparied

How can you promote independence at home with pt’s with impaired vision?

• Access technology to maximize independence (audio books, podcasts, reading software, large print, grocery delivery, meals that the pt can safely prepare alon)

• Remove fall risks (cords, rugs, furniture)

• Prefilled medication packs or med boxes

• Install non-skid bathtub surfaces and handrails

What are subjective findings with hearing problems?

• Subjective: eair pain or itching or drainage, vertigo or tinnitus, decreased hearing or understanding speech, stated hisotry may include use of hearing aid/ear infections/using instruments to clean ear (Qtip)/swimming/air travel/exposure to loud noises/history of smoking/HTN/DM/exposure to ototoxic medications

What are objective findings with hearing problems?

• Read body language, need for repeated information

• External ear

• Middle ear: normal tympanic membrane via otoscope

What are nursing interventions for hearing loss?

• Position yourself in front of pt

• Ensure you aren’t sitting or standing in front of a bright light or window which can interfere with the pt’s ability to see your lips move

• Make sure that the room is well lighted

• Get the pt’s attention before you begin to speak

• Move closer to the better-hearinge ar

• Speak clearly and slowly

• Do not shout (often makes it more difficult)

• Keep hands and otehr objects away from mouth when taking

• Have converstaions in quiet room with minimal distractions

• Have pt repeat statements

• Rephrase sentences and repeat info to aid understanding

• Use appropriate hand motions

• Write messages on paper if pt is able to read

What is otitis media?

• infection of middle ear causes inflammation and purulent exudate

• can perforate tympanic membrane, leading to scarring and hearing loss

• More common in young children

What do you assess and how do you diagnose/respond for otitis media?

• Assessment: pain, fever, dizziness, purulent/bloody discharge from ear (if perforated), N/V (especially in children), building of tympanic membrane visible via otoscope

• Diagnosis: symptoms, visualization via otoscope

• Respond: antibiotics (rarely, only needed for severe cases or long duration, usually resolve w/o), analgesics and other supportive care, surgery (“tubes”)

What pt teaching (prevention) should you provide for otitis media?

• Vaccinate: flu vaccine and pneumococcal vaccine (protects against a common cause of middle ear infections, Streptococcus pneumonia)

• Wash hand frequently

• Breast feed exclusively until age 6 months old, continue to breastfeed for at least 12 months

• Don’t smoke and avoid exposure to secondhand smoke

What are key concerns with burns?

• Imparied tissue integrity

• Pain

• Fluid and electrolyte imbalances

• Imparied gas exchange

• infection

• mobility

What are the different types of burns?

• Chemical

• Electrical

• Radiation

• Smoke → impaired gas exchange

• Thermal → fire

What are risk factors affectiving recovery from burns?

• Elderly

• Co-morbidities

What are complications (especially of severe burns) of burns?

• Inhalation injury and/or hypoxia

• Hypovalemic shock (fluids leak out of body fast and fluid voume decreases dramatically)

• Infection

• Scarring

• Contractures

What respiratory assessment findings are there with burns?

• airway edema

• tachypnea

• airway constriction

• alveoli damage

What do you focus on with a skin assessment regarding burns?

• Location: worse if face (nutrition and air), hands/feet (feed ourselves, move, ambulate, do ADLs), perinuem (ability to excrete), major joints (contracture and immobility)

• Extent: total body sruface area (TBSA)

• Depth: partial thickness, full thickness

What is the rule of nines and how does it differ for children and adults?

• Looks diferernt than childresn that it does for adults because children have a larger head than body size compared to adults

• Percentage of body that is burned adds up depending on where burn it: above a certain percentage or areas of body, the pt has to go to certified burn center

Regarding depth, what is a superficial burn?

• Only the top layer of skin- the epidermis

• Healing occurs in 3-6 days

• Just epidermis

Regarding depth, what is a superficial partial thickness burn?

• The entire epidermis and variable portions of the dermis layer of skin are destroyed. Uncomplicated healing occurs in 10-21 days

• Deep partial-thickness burns extend into the deeper layers of the dermis and healing occurs in 2-6 weeks

• Epidermis and dermis

Regarding depth, what is a full thickenss burn?

• Burns that reach through the entire dermis and sometimes into the subcutaneous fat

• The skin cannot heal on its own

• Epidermis, dermis and subcutaneous tissue

How can you prevent burns/what education can you provide?

• Sunscreen

• Clean chimneys yearly

• Smoke detectors, fire extinguishers

• Escape route for home fires

• Keep hot water tanks below 120 degrees

• Never smoke in bed or when drinking

• Keep lighters/matches away from children

• No smoking where home oxygen is in use

• Keep flammable objects away from space heaters

What are the different phases of burn treatment?

• Emergent (resuscitation)

• Acute (Healing)

• Rehabilitative (Restorative)

What is the burn response for the emergent (resuscitation) phase?

• Secure airway → TOP PRIORITY

  • Oxuygen, elevate HOB, intubate if needed

  • High flow O2 × 6+ hrs for carbon monoxide poisoning

• Support circulation and perfusion

• Mantain body temperature

• Provide emotional support

• Treat pain

What is the burn response for the acute (healing) phase?

• Maintain CV (due to hypovalemic shock, HIGEHST PRIORITY), Resp., and nutritional status

• Wound care

  • Hand hygiene, antibiotics, proper dressing, technique, tetanus vaccination, teach signs of infection

• Pain control: medicate 30min prior to dressing changes

• Psychsocial interventioins

What is the burn response for the rehabilitative (restorative) phase?

• Collaborate with interdisciplinary team

• Assist in psychosocial adjustment

• Prevent scars and contractures → compression, dressings

• Assist in resumption of pre-burn activity

What are the key concerns for musculoskeletal trauma?

• Sprains/strains → pain

• Amputations → pain, decreased tissue perfusion

• Fractures → hemorrhage and VTE, Fat embolism, infection or compartment syndrome (limb-threatening condition)

Difference between sprain and strain

• Sprain: excessive stretch of ligaments (swelling, inflammation, bruising, just for sprain??)

• Strain: excessive strecth of muscle and/or tendon

What are interventions for sprains/strains that are similar?

• Apply heat/cold

• Rest or limit activity

• Analgesics (especially NSAIDs)

How do interventions differe for sprains and strains?

• Sprains: compression and immobility advised, elevation

• Strains: possible surgical tendon repair required, muscle relaxants may be prescribed

For sprains and strains, what are subjective and objective assessment findings?

• Subjective: pain, decreased function

• Objective: edema, bruising

For sprains and strains what should you implement?

• Sprain:

  • RICE

    • Rest, immobilize with soft splint PRN

    • Ice intermittently for the first 24-48hrs

    • Compression for the first 24-48hrs

    • Elevate extremity

  • Analgesics

• Strain: apply heat/cold, activity limitations, NSAIDs and/or muscle relaxants, possible surgical tendon repair

What are the two different rypes of amputations?

• Elective

• Traumatic

What are complications of amputations?

• Hemorrhage

• Infection

• Phantom limb pain

• Flexion contracture

What should you monitor with amputations?

• Monitor tissue perfusion

• Traumatic → trying to manage bleeding/tissue perfusion until there is surgical intervention

  • Pressure, elevation → immediately to stop bleeding and help with perfusion until surgery

  • Do not remove dressing to prevent dislodging clot

  • Finger amputation care (specific care)

• Elective → making sure tissue prevention is maintained after surgical intervention

  • Monitor for hemorrhage and adequate perfusion at end of residual limb: proximal pulse, VS

How should you manage pain with amputations?

• Non-pharmacologic

• Pharmacologic:

  • Opioids ineffective for phantom limb pain (limb/tendons aren’t there)

  • May include beta-blockers, antiepileptic drugs (gabapentin), antispasmodics (baclofen)

How do you manage psycosocial concerns for amputations?

• Grieving process

• Interprofessional collaboration

How do you promote mobility with amputations?

• Collaborate with PT and OT- mobility aids, assistive devices and prosthetics

• ROM and PT exercises

• Dressings- elastic and rigid, removable dressings sculpt limb for prosthesis

How can you prevent infections with amputations?

• Antibiotics

• Monitor for signs/symptoms of infection

What is a fracture?

• Any break or disruption in continuity of bone

• Classified by:

  • Extent of break (complete- breaks all the way through, displaced- bone snaps completely and moves out of alignment, incomplete- bone cracks or bends, but it does not break completely through into separate pieces)

  • Associated soft-tissue famage (open- broken bone punctures and pierces through the skin, closed- bone breaks, but the surrounding skin and tissue remain intact with no open wound or puncture)

What are causes of a fracture?

• Pathologic: after trauma or related to disease

• Fatigue (stress): excessive strain on the bone

• Compression: vertebrae of elderly most common

What are complications of fractures?

• Hemorrhage and VTE

• Fat embolism: monitor for hypoxemia, dyspnea, tachypnea

• Infection: osteomyelitis, especially with open fractures/surgical repair

• Acute compartment syndrome: ischemia and edema cause increased pressure within fascial compartment, limb-threatening condition

What are the 6 P’s of compartment syndrome?

• Paresthesia (early symptom)

• Pain

• Pressure

• Pallor

• Paralysis

• Pulseless

What are causes of compartment syndrome?

• Can be caused by external pressure OR internal pressure

• Can also occur due to severe burns, extensive insect/snake bites, or massive infiltration of IV fluids

• Can lead to infection, persistence motor weakness, contracture, amputation

What are subjective and objective assessment findings for fractures?

• Subjective: pain, decreased function or movement, spasm

• Objective: possible trauma to other body systems, deformity, edema, bruising/bleeding, guarding, crepitus, neurovascular changes, shock

How do you increase mobility with fractures?

• Collaborate with PT and OT

• Use of mobility aids

• Prevent complications or immobility

How can you prevent infection with fractures?

• Use aseptic technique

• Administer antibiotics as ordered

• Monitor for symptoms of infection

How can you prevent neuromuscular compromise for fractures?

• Perform 6 P’s

• Loosen dressings if needed

• Prepare for surgical fasciotomy if needed

What are non-surgical methods to manage pain with fractures?

• Opiods, NSAIDs, acetaminophen

• Splints, Boots and Casts

• Closed reduction

• Physica therapy (after acute period)

• Traction

  • Skeletal traction: pins inserted into bone- monitor for drainage/infection

  • Weights hang from ropes/pulleys: monitor consistency application of weights, weight should not touch floor, monitor for neurovascular compromise

What are surgical methods to manage pain for fractures?

• Open reduction with internal fixation (ORIF)

• External fixation: monitor pin sites for infection- purulent exudate and severe redness (clear drainage and slight erythema are expected findings)

What patient teaching should you provide with fractures?

• Casts: elevate extremity to reduce swelling, ice 24-48 hrs, use sling (if arm affected) for first few days, self-monitor for neurovascular compromise, do not insert anything into cast or get it wet

• Wound care and monitoring for infection (increase in pain or odor)

• Use of assistive devices- ensure safety at home

• Nutrition: high protein, calcium, iron

What are the priority concerns for elective or traumatic amputations?

• Imparied (tissue) perfusion

• Pain

• Grief, fear, anxiety

• Impaired mobility

• Risk for infection

What are interventions for impaired (tissue) perfusion with amputations?

• Traumatic: pressure and elevation, leave dressing intact (don’t dislodge clot)

• Elective/planned: proximal pulse, color/sensation/movement VS

What are interventions for pain with amputations?

• Non-pharmacist approaches

• Opiods ineffective

• Beta-blockers

• Antiepileptic drugs (gabapentin)

• Antispasmodics (baclofen)

• Mirror therapy

What are interventions for grief, fear, anxiety with amputations?

• Therapeutic communication

• Collaborate with chaplain

• Social worker

• Psychologist

What are interventions for impaired mobility with amputations?

• Collaborate w/PT/OT (mobility aids, assistive devices, prosthetics, ROM an dPT exercises)

• Specialized dressings

What are interventions for risk for infection with amputations?

• Antibiotics

• Monitor for S/S of infection

• Teach client S/S

What does TBSA, ORIF, and CMS/CMST stand for?

• TBSA: totaly body surface area

• ORIF: Open reduction, internal fixation

• CMS/CMST: limb assessment including circulation (pulse), motor (movement), sensation (numbness/tingling), temperature (skin)

On discharge what teaching should be included for a pt with a fracture and cast?

• Elevate extremity to reduce swelling

• Ice x 24-48hrs (if recent injury)

• Use of assistive devices and/or sling while casted

• Weight bearing limitations

• Self-monitor for neurovascular compromise

• Do not insert anything into cast or get it wet

What factors affect health equity for pt’s with skin, hair, or nail health problems?

• Skin health

• Drug, remedies, substance Hx

• Allergen Hx

• Nutrition Hx

• Family Hx and Genetic risk

• Social Hx- demographic information, skin color (Fitzpatrick Skin Phototype Classification)

What are the different types in the fitzpatrick skin classification scale?

• Type 1: white, very fair, freckles, typical albino skin → always burns, never tans

• Type 2: White, fair → usually burns, tans with difficulty

• Type 3: Beige, very common → sometimes mild burn, gradually tans to a light brown

• Type 4: Beige with a brown tint, typical mediterranean white skin → rarely bruns, tans with ease to a moderate brown

• Type 5: Dark brown → very rarely burns, tans very easily

• Type 6: Black → never burns, tans very easily, deeply pigmented

How do you assess for pressure injuries and what are interventions?

• Assess risk level: assess skin, assess nutrition, assess fluid intake

• Interventions: reduce pressure → patient positioning, devices and improve pressure tolerance → cleanliness, moisture management

What increases a pt’s risk for skin, hair, or nail health problems?

• Irritation skin disorders

• Inflammatory skin disorders

• Skin infections

• Parasitic disorders

• Skin cancer

• Life threatening skin disorders

How do you plan care for skin, hair, or nail health problems?

• Assess

• Diagnose

• Plan: SMART goals

• Implementation: cleanliness, hydration, nutrition, medication, light exposure, movement, support, educate

What education should you provide for skin, hair, or nail health problems?

• Take a complete bath or shower every other day using tepid water, wash the face, axilla, perineum, and any solid areas with soap daily (use a superfatted/nonalkaline soap, rinse throughouly, oatmeal baths can be soothing, if desried apply oil to the skin at end of shower/bath, pat skin surfaces dry- do not rub)

• Avoid use of products such as deodorant soap, perfumes, and lotions made with alcohol or other drying agents

• Avoid clothing that continuously rubs the skin, such as tight belts and pantyhose

• Maintain a daily fluid intake of 3000mL unless contraindicated for another medical reason

• Do not apply rubbing alcohol, astringents or other drying agents to the skin

• Avoid caffeine and alcohol ingestion

• Use a room humidifier during cold months or whenever the furnace is in use

• Maintain a cool, comfortable sleeping environment

• Avoid sun exposrue during midday

• Avoid tanning beds

• Use sunscreen
  Wear heat, opaque clothing, and sunglassess

• Examine body for possibly cancerous or precancerous lesions

• Keep a “body map” of skin to know when changes have occurred

• Take pictures of lesions and compare

For skin, hair, or nail health problems when should you contact your HCP?

• Color change of a lesion, especially if it darkens or shows evidence of speading

• Size change of a lesion, especially rapid growth

• Shape change of a lesion, such as a sharp border becoming irregular or flat lesion becoming raised

• Redness/hyperpigmentation or swelling of the skin around a lesion

• Sensation changes, especially itching or increased tenderness of a lesion

• Character changes of a lesion, such as oozing, crusting, bleeding, or scaling