Dehiscence And Evisceration, And Nursing Interventions

Topics Review for System Exam #1: -Dehiscence and evisceration; and nursing interventions What is dehiscence? ● When an incision fails to heal properly, the layers of skin and tissue separate. ● Dehiscence is the partial or total separation of wound layers. What is evisceration? ● total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) occurs. *organs are coming out of the incision* Who is at risk for dehiscence? - A patient who is at risk for poor wound healing (e.g., poor nutritional status, infection) is at risk for dehiscence. What might cause dehiscence? What might prevent it? ● Dehiscence can happen in abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. NURSING INTERVENTION: What is an evisceration considered? What are your actions as the LVN? ● Evisceration is a surgical emergency. ● Immediately place sterile gauze soaked in sterile saline over the site to reduce chances of bacterial invasion and drying of the tissues, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery. Calculate rule of nines What is the meaning of the Rule of nines? ● The rule of nines provides a means of determining (estimating) the percentage of the body that is burned ➔ Percentage of Head and Neck ( Adult ) ➔ Anterior: 4.5% ➔ Posterior: 4.5% ➔ Total= 9% ➔ Percentage of Trunk (Adult) ➔ Posterior:18% ➔ Anterior: 18% ➔ Percentage of Each Upper Extremity (Adult ) ➔ Anterior: 4.5% ➔ Posterior: 4.5% ➔ Total= 9% ➔ Percentage of External Genitalia ( Adult ) ➔ 1% ➔ Percentage of Each Lower Extremity( Adult ) ➔ 18% ➔ Anterior: 9% ➔ Posterior: 9% ➔ Percentage of Chest( Adult ) ➔ 9% ➔ Percentage of Abdomen ( Adult ) = 18% ➔ 9% Types of burns First degree (superficial) burns Second degree (partial thickness) burns Affects only the epidermis; No blisters; Mildly painful Involves epidermis and portions of the upper and lower dermis. Red and moist burn site, which is blistered, swollen and very painful. Third degree (full thickness) burns Extends through the dermis and into the hypodermis. The burn site is patchy, causing little or no pain. Thermal Burns: the most common. They are caused by house fires and car accidents. They can also be caused by playing with matches and firecrackers. Other thermal burns are caused by scalding water, irons, stoves, and sunburn. Chemical Burns : Are caused by contact with acids or alkaline. Contact includes ingesting, inhalation, and injection. People who work with harmful chemicals must take precautions to avoid contact with the skin or inhalation of dangerous fumes. Electrical Burns: Are caused by faulty electrical wiring, chewing on electrical cords, high-voltage power lines, and the rare occurrence of lightning strikes. Electrical burns can pose a unique problem for health care workers. Treatment depends on whether or not the patient needs to be separated from the electrical source. Stage 1: non blanchable redness redness that stays there stage 2: partial thickness thickness of skin has been when you press down on it in localized area lost, dermis is exposed and is pink and moist stage 3: full thickness skin loss epidermis and dermis is stage 4: full thickness tissue loss bone/muscle visible and unstageable full tissue loss with actual lost, subcutaneous layer of skin is exposed slough and eschar may be visible (dead tissue) depth of an ulcer completely obscured by slough What is Psoriasis? - skin disease that causes red, itchy scaly patches, most commonly on the knees, elbows, trunk and scalp. Psoriasis is a common, long-term (chronic) disease with no cure. Clinical Manifestations ➔ Pruritus (itchy skin is often caused by dry skin) ➔ Raised silvery, scaly, plaques in elbows, knees, and scalp How to Diagnose? To diagnose psoriasis, a dermatologist will examine your skin, nails, and scalp for signs of this condition. - Symptoms, such as itchy skin. Joint problems, such as pain and swelling or stiffness when you wake up. Complications of Psoriasis ➔ Impaired mobility ➔ Stress/anxiety ➔ Dehydration ➔ Hypothermia ➔ Infection The skill cells divide much more rapidly than normal. The normal time for the entire skin to be replaced through Sloughing and generation of new cells is 28 days, in psoriasis the time may decrease to 7 days. Severe scaling results from the rapid cell division. Medical Management ● Slow down skin cell regeneration process ● Topical steroids and Keratolyctic agents are used in occlusive wet dressings to decrease inflammation. ● Topical steroids: Hydrocortisone and betamethasone valerate (Valisone) ● Keratolytic agents : Tar prep to reduce shedding of skin ● Methotrexate and Vitamin D: reduce epidermal proliferation in some cases. Nursing Interventions ● Encourage support groups ● Counseling Prognosis – Chronic disease -Paronychia ● Paronychia: nails get soft and brittle and shape can change as they grow into the soft tissue (ingrown nails). ● An infection of the nail develops and spreads around the nail. ● Wet dressings or topical antibiotics may be used. ● Sometimes Surgical incision and drainage of the infected area are performed. -Cellulitis Cellulitis: an acute infection of the dermis and underlying connective tissue (COMMON BACTERIA STAPHYLOCOCCUS) Diagnostics ● Culture ( blood, purulent exudate, tissue specimen) Cellulitis Medical Management ● Antibiotics (Penicillin, cephalexin, erythromycin) ● Pain control Cellulitis Nursing Interventions ● Administer antibiotics and pain medications ● Assess pain ● Apply warm, moist dressing to decrease discomfort Cellulitis Prognosis ● Cure with treatment 7-10 days Cellulitis Complications ● Sepsis - blood poisoning; the body's often deadly response to infection or injury - CODE SEPSIS, PATIENT HAS 6-10 HOURS BEFORE BLOOD INFECTION CAN KILL THE PATIENT. ● Meningitis (an inflammation of the meninges, which are the membranes that protect the brain and spinal cord) ● Lymphangitis (Inflammation of lymph vessels) -Contact dermatitis ● ● Direct contact with agents to which a person is hypersensitive Common causes of dermatitis: DETERGENTS, SOAPS, INDUSTRIAL CHEMICALS AND PLANTS, SUCH AS POISON IVY. Contact Dermatitis Manifestations and Assessment ● Erythema (red rash, irritated) ● Papules (skin lesions) ● Vesicles (eczema involving the fingers, hands) Contact Dermatitis Medical Management ● Antihistamines – Common example? - Diphenhydramine (Benadryl) Contact Dermatitis Nursing Intervention ➔ Wet dressings ➔ Cold compresses ➔ Daily baths ➔ Corticosteroids Prognosis •Full recovery -Herpes zoster Herpes Zoster ● Commonly referred to as shingles ● Caused by same virus as chickenpox ● A person with shingles has a history of chickenpox infection. ● The virus causes an inflammation of the spinal ganglia and produces skin lesions of small vesicles along the peripheral nerve fibers on the spinal ganglia. Risk factors: suppressed immunity, aging, infection, and stress. Herpes Zoster Manifestations