NLE Integumentary & Skin Integrity — Burns and Dermatologic DisordersConcept Map

Concept

Burns

Sub Concepts

• Classification by Depth
• TBSA Estimation
• Pathophysiology
• Fluid Resuscitation
• Clinical Phases
• Complications
• Pharmacology

Relationship To Central

Acute traumatic injury to integumentary system requiring emergency assessment and multi-phase management

Concept

Dermatologic Disorders

Sub Concepts

• Inflammatory Disorders
• Infectious Disorders
• Assessment and Management
• Psychosocial Considerations

Relationship To Central

Chronic or acute non-traumatic skin conditions requiring therapeutic management and patient education

Concept

Nursing Process Application

Sub Concepts

• Assessment Techniques
• Nursing Diagnoses
• Priority Setting
• Interventions
• Evaluation

Relationship To Central

Systematic approach to assessment, diagnosis, planning, implementation, and evaluation using NANDA taxonomy

To

TBSA Estimation

From

Burn Depth Classification

Strength

strong

Relationship

Only partial-thickness and full-thickness burns (second-degree and deeper) are counted toward TBSA; superficial first-degree burns are excluded from calculations

To

Parkland Formula

From

TBSA Estimation

Strength

strong

Relationship

TBSA percentage is a critical variable in the Parkland formula calculation: 4 mL × kg × %TBSA = total fluid for 24 hours

To

Fluid Resuscitation Monitoring

From

Parkland Formula

Strength

strong

Relationship

The formula provides initial fluid volume, but urine output (0.5 mL/kg/hr in adults) is the primary indicator guiding titration and adequacy assessment

To

Hyperkalemia

From

Emergent Phase Pathophysiology

Strength

strong

Relationship

Cellular destruction and massive fluid shifts release potassium into the intravascular space, causing life-threatening hyperkalemia requiring cardiac monitoring

To

Hypokalemia

From

Acute Phase Pathophysiology

Strength

strong

Relationship

As fluid shifts reverse and diuresis begins, potassium re-enters cells and is lost in urine, shifting the electrolyte balance from hyper- to hypokalemia

To

Acute Phase

From

Infection Risk

Strength

strong

Relationship

Infection and sepsis become the primary threat during the acute phase as the immune response is impaired and the wound becomes colonized with bacteria

To

Rehabilitation Phase

From

Contractures

Strength

strong

Relationship

Contractures are the most common late complication of burns and develop despite early intervention; prevention requires positioning, splinting, and continuous ROM exercise

To

Autoimmune Pathology

From

Psoriasis

Strength

moderate

Relationship

Psoriasis is a chronic autoimmune disorder of accelerated epidermal cell turnover resulting in characteristic silvery plaques on extensor surfaces

To

Inflammatory Response

From

Dermatitis

Strength

moderate

Relationship

Dermatitis represents an acute or chronic inflammatory response to irritants or allergens, manageable but not curative

To

Bacterial Infection

From

Cellulitis

Strength

strong

Relationship

Cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue requiring systemic antibiotics and requiring infection control monitoring

To

Airway Priority

From

Inhalation Injury

Strength

strong

Relationship

Inhalation injury is the leading cause of early death in burn victims and requires immediate airway assessment and 100% humidified oxygen

To

Myoglobinuria

From

Electrical Burns

Strength

strong

Relationship

Electrical burns cause deep tissue damage leading to rhabdomyolysis, myoglobinuria (dark urine), and risk of acute kidney injury requiring aggressive fluid resuscitation

To

Stress Response

From

Curling Ulcer

Strength

moderate

Relationship

Curling ulcer (stress-related gastric ulcer) is a common complication requiring prophylactic proton pump inhibitors or H2 blockers during acute phase

To

Pain Level

From

Burn Depth

Strength

strong

Relationship

Superficial partial-thickness burns are the most painful (intact nerve endings); full-thickness burns are painless (nerves destroyed); deep partial-thickness burns have intermediate pain

To

Rehabilitation Phase Initiation

From

Wound Closure

Strength

strong

Relationship

The rehabilitation phase begins once wound closure is achieved, shifting focus from resuscitation and infection prevention to function restoration and appearance

To

Topical Antimicrobial

From

Silver Sulfadiazine

Strength

moderate

Relationship

Silver sulfadiazine is a broad-spectrum topical agent commonly used for burn wounds; contraindicated in sulfa allergy and requires monitoring for transient leukopenia

To

Eschar Penetration

From

Mafenide Acetate

Strength

moderate

Relationship

Mafenide acetate penetrates eschar effectively, useful over cartilage, but causes painful application and metabolic acidosis through carbonic anhydrase inhibition

To

Maslow Prioritization

From

NANDA Nursing Diagnoses

Strength

strong

Relationship

Nursing diagnoses are organized using Maslow's hierarchy: physiological needs (airway, fluid, pain) take priority over safety, belonging, esteem, and self-actualization

To

Nursing Diagnosis

From

Assessment

Strength

strong

Relationship

Comprehensive assessment guides selection of appropriate NANDA nursing diagnoses, which form the basis for planned interventions and patient outcomes

To

Nursing Practice Standards

From

RA 9173

Strength

moderate

Relationship

The Nursing Law (RA 9173) defines the scope and competencies expected of Filipino nurses, including assessment, intervention, patient education, and documentation in burn and dermatologic care