ADULT NURSING

Management of
clients
- Burn Injury
- Diabetes Mellitus
Lecturer: Mr Steve Mohammed

GROUP MEMBERS
CHRISTAL PARIS
symptoms
AARON WALLACE
SUNITA RAMSARAN
disorders
ANEESHA ALI GHANY
AKEELA TRIM
mellitus Type 123

- related causes,
- phase of burn care,
psychological
- common skin
- hyperglycemic
- diabetes

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
Fire
Contact

Radiation

Chemical

Electrical
Scald

TYPES OF BURNS

TYPES OF BURNS

TYPES OF BURNS

ASSESSMENT OF BURNS
The rule of nine.
Lund Browder method.
Palmer method.

RULE OF NINES
Anestimation of the TBSA involved in a burn is simplified
by using therule 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.

Wallaces Rule of Nines.

LUND & BROWDER

A more precise METHOD
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 patients
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 patients 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 DEBRIDEMENT
As 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/SURGICA
L

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.

AUTOGRAFTS
Autografts are the ideal means of
covering burn wounds because the grafts
are the patients own skin and thus are
not rejected by the patients 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 dressings
Heterograft, 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
Dermatologists, reconstructive & cosmetic surgeons
COSMETIC

within

the specialty can improve the physical look

& feel of the

scar, which, in turn, often leads to an

improvement in the

persons 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
ECZEMA (atopic
dermatitis)
DISORDER
- 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 METHOD
Aimed 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).

LUPUS

COMMON SKIN
DISORDER

Anautoimmunedisease.
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 hairdressers 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).

Psoriasis

COMMON SKIN
DISORDER

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 & halfnormal saline
Observe for signs of hypoglycemia
Perform finger stick glucose testing
Identify food preferences, includingethnic 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 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
and half-normal saline
Observe for signs of hypoglycemia
Perform finger stick glucose testing
Identify food preferences, including ethnic
and cultural needs

TREATMENT METHOD
Meal planning
Exercise
Insulin
Anti-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 MAIN

CLINICAL FEATURES OF DKA ARE:
Hyperglycemia
Dehydration and electrolyte loss
Acidosis

CLINICAL SIGNS AND SYMPTOMS

Hyperglycemia signs of DKA
Polydipsia
Polyurea
Blurred vision,
Weakness
Headache

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 patients laboratory values and the frequent changes
in fluids and medications that are prescribed and monitors the
patients 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 electrolytes
Rehydration
Reversing Acidosis

HYPERGLYCEMIC HYPEROSMOLAR
NONKETOTIC 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
commonly
affected

Can occur in type 1

or type 2
diabetes; more
common in type 1

Can occur in type 1

or type 2
patients; more
common in type 2
diabetes

Precipitating event

Omission of insulin;
physiologic
stress (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

300350 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 Medicalsurgical 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://nandanursinginterventions.blogspot.com/2011/05/nu
rsing-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/traumaburn/about/burn-center/Documents/04%20The%20Skin_Burn%20Wo
s_Treatment.pdf

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

http://intranet.tdmu.edu.ua/data/kafedra/internal/distance/cl
asses_stud/English/1course/Professional%20Nursing%20Role%20Tr
ansition%20Practicum/35.%20Practice%20nursing%20care%20for%
Clients%20with%20Burns.htm
http://www.woundsinternational.com/media/issues/284/files/conten
t_8833.pdf

Endocrine disorders. (2012). In Medicalsurgical 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://nandanursinginterventions.blogspot.com/2011/05/
nursing-intervention-for-diabetes.html

THE END