NLE Integumentary & Skin Integrity — Burns and Dermatologic DisordersDetailed Explanation

Burn Classification by Depth

Burns are classified based on the depth of tissue destruction — that is, how many layers of skin are involved. Understanding depth determines pain level, healing potential, need for grafting, and nursing interventions. **Superficial (First-Degree) Burns** Only the outermost layer — the epidermis — is involved. The hallmark signs are: RED skin, DRY surface, PAINFUL, and BLANCHES with pressure. There are NO blisters. The classic example is a sunburn (tirik ng araw). These burns heal within 3–6 days without scarring and are NOT counted in TBSA calculation for fluid resuscitation. **Superficial Partial-Thickness (Second-Degree) Burns** The epidermis and the UPPER dermis are destroyed. These are identified by: BLISTERS (bullae), a MOIST and WEEPING surface, SEVERE PAIN (because nerve endings are intact and exposed), and BLANCHING. Healing takes 2–3 weeks, usually without grafting. **Deep Partial-Thickness (Second-Degree) Burns** These extend into the DEEPER dermis. They appear RED to WAXY WHITE, are DRIER than superficial partial-thickness burns, and have LESS PAIN because some nerve endings have been destroyed. Capillary refill is sluggish. These may require skin grafting and are prone to scarring. **Full-Thickness (Third-Degree) Burns** The ENTIRE epidermis and dermis are destroyed, possibly extending into subcutaneous fat. Key features: DRY, LEATHERY, INELASTIC ESCHAR; color ranges from white/waxy to tan, brown, or charred; the wound is PAINLESS in the center because all nerve endings are destroyed. Does NOT blanch. ALWAYS requires skin grafting — the wound cannot heal on its own. **Fourth-Degree Burns** Extend into muscle, fascia, and bone. Charred appearance. May require amputation. Associated with electrical burns. **Key Nursing Insight:** The most PAINFUL burn is superficial partial-thickness (second-degree) because nerve endings are intact and exposed. Full-thickness burns are PAINLESS at the center — a student who touches a third-degree burn expecting pain will be surprised. This distinction is a common NLE trap.

Rule of Nines and TBSA Estimation

Accurately estimating the Total Body Surface Area (TBSA) burned is essential because it directly drives the Parkland formula calculation. Overestimating leads to fluid overload; underestimating causes hypovolemic shock. **The Rule of Nines (Adult)** The adult body is divided into anatomical regions, each representing a percentage of total body surface area in multiples of 9: | Body Region | TBSA % | |---|---| | Head and Neck | 9% | | Each Arm (upper + lower + hand) | 9% | | Anterior Trunk (chest + abdomen) | 18% | | Posterior Trunk (back) | 18% | | Each Leg (thigh + lower leg + foot) | 18% | | Perineum/Genitalia | 1% | | **TOTAL** | **100%** | **How to Count:** Each arm = 9% (two arms = 18%); each leg = 18% (two legs = 36%). Head and neck = 9%. Anterior trunk = 18%. Posterior trunk = 18%. Perineum = 1%. Total = 100%. **Critical Rule:** Only PARTIAL-THICKNESS and FULL-THICKNESS burns are counted. First-degree (superficial) burns are EXCLUDED. **Lund-Browder Chart** For children, the Rule of Nines is inaccurate because children have proportionally LARGER HEADS and SMALLER LEGS than adults. The Lund-Browder chart adjusts for age-related body proportions and is more accurate for pediatric patients. **Palmar Method (Rule of Palm)** For scattered or irregular burns, use the patient's own PALM (including fingers) as approximately 1% TBSA. This is useful for patchy burns across multiple body areas. **NLE Application Example:** A patient has burns covering: entire right arm (9%) + anterior chest only (9%) + anterior abdomen only (9%) + perineum (1%) = 28% TBSA Note: Anterior trunk = 18% total; the chest is the upper half (9%) and the abdomen is the lower half (9%). **Memory Aid (Isip-isip Natin):** Think of the body as divided into 11 sections of 9% each, plus 1% for perineum = 100%. Arms are the small ones (9% each), legs are the big ones (18% each).

Parkland Formula for Fluid Resuscitation

The Parkland (Baxter) formula is the standard method for calculating intravenous fluid replacement in major burns. It prevents hypovolemic shock caused by massive fluid shifts from the vascular space into the tissues (third-spacing). **THE FORMULA:** **4 mL × Body Weight (kg) × %TBSA burned = Total fluid volume for the first 24 hours** **Solution: Lactated Ringer's (LR)** — not normal saline, not D5W **The Critical Timing Rule:** - Give **HALF (50%)** of the total volume in the **FIRST 8 HOURS** — calculated from the **TIME OF INJURY**, NOT from when the IV was started - Give the **REMAINING HALF** over the **NEXT 16 HOURS** **WHY LACTATED RINGER'S?** LR is an isotonic crystalloid that best replaces the interstitial fluid losses from burns. It contains electrolytes close to plasma composition. **WORKED EXAMPLE (NLE-style):** Patient: 70 kg adult, 40% TBSA burn - Total = 4 × 70 × 40 = **11,200 mL** in 24 hours - First half = 5,600 mL in the first 8 hours from injury - Hourly rate for first 8 hours = 5,600 ÷ 8 = **700 mL/hr** - Second half = 5,600 mL over the next 16 hours - Hourly rate for next 16 hours = 5,600 ÷ 16 = **350 mL/hr** **THE TIME-FROM-INJURY TRAP (Very Common in NLE):** If the patient was burned 2 hours before reaching the hospital, the nurse has only 6 hours left to deliver the first-8-hour volume. - Example: Patient injured at 8:00 AM, IV started at 10:00 AM. - The first 8 hours end at 4:00 PM (8 hours from injury). - The first-half volume must be infused in the REMAINING 6 hours, not 8 hours. - New rate = 5,600 ÷ 6 = **933 mL/hr** **MONITORING RESUSCITATION ADEQUACY:** The BEST indicator of adequate fluid resuscitation is **URINE OUTPUT**: - Adults: **0.5 mL/kg/hr (approximately 30–50 mL/hr)** - Children: **1 mL/kg/hr** If urine output falls below target → increase fluid rate. If urine output exceeds target significantly → may be over-resuscitating. **Day 2 Onwards:** Colloidal solutions (albumin) may be added after 24 hours when capillary permeability begins to normalize. The Parkland formula strictly governs Day 1 resuscitation.

Phases of Burn Injury

Burn care is organized into three distinct clinical phases, each with specific pathophysiological changes, electrolyte imbalances, priority assessments, and nursing interventions. Understanding phase-specific changes is critical for NLE prioritization questions. --- **PHASE 1: EMERGENT (RESUSCITATIVE) PHASE** Timeframe: From time of injury to 24–48 hours Pathophysiology: Massive capillary leakage causes fluid to shift FROM the bloodstream INTO the interstitial space (THIRD-SPACING). This leads to: - HYPOVOLEMIA (low blood volume — the big danger) - EDEMA at and around the burn site - HEMOCONCENTRATION (elevated hematocrit, elevated BUN — blood becomes concentrated) - HYPERKALEMIA — damaged cells release intracellular potassium into the bloodstream - HYPONATREMIA — sodium is trapped in edema fluid and lost in exudate Greatest Threat: **HYPOVOLEMIC (BURN) SHOCK** Nursing Priorities (Maslow: Physiological — Survival needs): 1. **AIRWAY FIRST** — assess for inhalation injury: facial burns, singed nasal hairs, carbonaceous (sooty) sputum, hoarseness, stridor, or history of enclosed-space fire. Give 100% humidified oxygen. Prepare for early intubation — airway edema can close the airway rapidly. 2. **Fluid resuscitation** — Parkland formula with Lactated Ringer's; insert large-bore IV (two IVs if possible) 3. **Foley catheter** — monitor hourly urine output 4. **Pain management** — IV opioids ONLY (IM/SC absorption is unreliable due to edema and poor peripheral perfusion) 5. **Escharotomy** — if circumferential burns are compromising circulation or breathing 6. **Keep patient NPO** — risk of paralytic ileus 7. **Warmth** — large burns lose body heat rapidly (hypothermia risk) --- **PHASE 2: ACUTE PHASE** Timeframe: From 48–72 hours post-burn until wound closure Pathophysiology: Capillary integrity is restored; fluid SHIFTS BACK into the vascular space. Results in: - DIURESIS (large urine output — watch for fluid overload) - HYPOKALEMIA — potassium re-enters cells AND is lost in large urine output - Sodium normalizes - INFECTION and SEPSIS become the primary threats Greatest Threat: **INFECTION AND SEPSIS** (burn wound is a massive open wound) Nursing Priorities: 1. **Wound care** — cleaning, debridement, topical antimicrobials, dressings; prepare for skin grafting (full-thickness burns) 2. **Infection prevention** — strict aseptic technique; protective/reverse isolation; monitor for sepsis signs 3. **Nutrition** — burns are HYPERMETABOLIC; HIGH-CALORIE, HIGH-PROTEIN diet; early enteral feeding; supplement with Vitamin C, Vitamin A, and Zinc for wound healing 4. **Curling's ulcer prophylaxis** — proton pump inhibitors (e.g., omeprazole) or H2 blockers (e.g., ranitidine) to prevent stress-induced gastric ulcers 5. **Positioning and splinting** — begin early to prevent contractures 6. **Monitor for hypokalemia** — replace potassium as ordered --- **PHASE 3: REHABILITATION PHASE** Timeframe: From wound closure onward (can last months to years) Focus: Restore function, minimize scarring, support psychosocial recovery. Greatest Threat: **CONTRACTURES** (most common late complication) Nursing Priorities: 1. **Prevent contractures** — position joints in EXTENSION, use splints, encourage active ROM exercises 2. **Pressure garments** — reduce hypertrophic scarring; worn 23 hours/day for up to 1–2 years 3. **Psychosocial support** — address body image disturbance (NANDA: Disturbed Body Image), grief, depression 4. **Scar management** — scar maturation takes up to 1–2 years 5. **Community reintegration** — refer to physical therapy, occupational therapy, social work, and support groups --- **PHASE ELECTROLYTE SUMMARY (Very High-Yield for NLE):** - Emergent: HYPERKALEMIA (cells release K+) + HYPONATREMIA (Na+ trapped in edema) - Acute: HYPOKALEMIA (K+ re-enters cells, lost in urine) + DIURESIS

Burn Pharmacology and Special Burn Types

Pharmacological management in burns targets infection prevention, pain relief, tetanus protection, and electrolyte correction. Special burn types (electrical, chemical, inhalation) carry unique assessment priorities. --- **TOPICAL ANTIMICROBIALS:** **Silver Sulfadiazine (Silvadene)** - Most commonly used topical antimicrobial in burn care - Broad-spectrum activity against gram-positive, gram-negative bacteria, and Candida - Side effect: TRANSIENT LEUKOPENIA (decreased WBC count) — monitor CBC - Contraindicated in: Sulfa allergy, near-term pregnancy (third trimester), and newborns (risk of kernicterus) - Applied with sterile technique; has a white cream appearance **Mafenide Acetate (Sulfamylon)** - Penetrates ESCHAR effectively — ideal for cartilage burns (ear, nose) where silver sulfadiazine cannot penetrate - Side effects: PAINFUL on application (significant burning sensation) and causes METABOLIC ACIDOSIS by inhibiting carbonic anhydrase (the enzyme that converts CO₂ to bicarbonate) - Monitor: Blood gas values (watch for decreasing bicarbonate, decreasing pH) - Also a sulfonamide — use caution in sulfa allergy **Silver-Impregnated Dressings (e.g., Mepilex Ag, Aquacel Ag)** - Newer alternatives with sustained silver release; less frequent dressing changes needed **Bacitracin/Polymyxin** - Used for superficial partial-thickness burns and facial burns --- **ANALGESIA:** - **IV opioids** (Morphine, Fentanyl) — standard for burn pain; IV route ONLY during emergent phase - Ketamine — useful for dressing changes (provides analgesia and dissociative anesthesia) - NSAIDs and anxiolytics may supplement opioids **TETANUS PROPHYLAXIS:** Burns are TETANUS-PRONE wounds. All burn patients must receive tetanus toxoid. If immunization status is unknown or incomplete, also give tetanus immune globulin (TIG). **SYSTEMIC ANTIBIOTICS:** Used ONLY for DOCUMENTED INFECTION (confirmed by wound culture). NOT given prophylactically to avoid antibiotic resistance. Signs of burn sepsis include altered mental status, temperature instability, glucose fluctuations, and new ileus. --- **SPECIAL BURN TYPES:** **Electrical Burns:** - Surface wound appears DECEPTIVELY SMALL but DEEP tissue damage is extensive - Current follows nerves and blood vessels, causing internal destruction - Priority: Monitor for CARDIAC DYSRHYTHMIAS (place on cardiac monitor immediately) - Risk of MYOGLOBINURIA/RHABDOMYOLYSIS — myoglobin from damaged muscle clogs the kidneys → DARK (cola-colored) URINE → ACUTE KIDNEY INJURY - Intervention: Increase IV fluids to flush myoglobin; target urine output 1–2 mL/kg/hr in electrical burns - Check entry and exit wound sites **Chemical Burns:** - Do NOT use neutralizing agents — generates heat and causes further injury - For DRY CHEMICAL AGENTS: BRUSH OFF the powder FIRST before flushing - Then FLOOD/IRRIGATE with copious water or saline for at least 20–30 minutes - Alkali burns (lye, cement) penetrate deeper than acid burns — may appear deceptively mild initially - Flush eyes with water immediately if chemical eye exposure occurred **Inhalation Burns:** - LEADING CAUSE OF EARLY DEATH in burn patients - Suspect if: facial burns, singed nasal hairs (nangatutupok na buhok ng ilong), carbonaceous (sooty) sputum, hoarseness, stridor, history of fire in an enclosed space - CARBON MONOXIDE POISONING: CO binds hemoglobin 200× more strongly than O₂ → tissue hypoxia despite normal SpO₂ on pulse oximetry (pulse ox CANNOT distinguish oxyhemoglobin from carboxyhemoglobin) - Intervention: 100% HUMIDIFIED OXYGEN via non-rebreather mask - Prepare for EARLY INTUBATION — airway edema can close the airway within hours

Dermatologic Disorders: Dermatitis, Psoriasis, Cellulitis, and Skin Infections

Beyond burns, the NLE regularly tests knowledge of common skin disorders encountered in Philippine clinical practice. Each disorder has distinct pathophysiology, clinical features, and nursing management. --- **DERMATITIS (ECZEMA)** Inflammation of the skin. Two major types: *Contact Dermatitis:* - Irritant type: Caused by direct chemical irritation (soap, detergent, urine) - Allergic type: Type IV hypersensitivity reaction (delayed hypersensitivity); examples: nickel jewelry, latex, plants - Key features: Erythema, pruritus (itching), vesicles, and scaling in the area of contact - Patch testing identifies the allergen *Atopic Dermatitis:* - Chronic, relapsing condition associated with personal or family history of asthma, allergic rhinitis (atopic triad) - Common in children; often improves with age - Features: intense pruritus, dry skin, lichenification (thickening from chronic scratching) *Nursing Management:* - Identify and AVOID triggers - EMOLLIENTS/MOISTURIZERS (apply immediately after bathing while skin is slightly moist) - Topical CORTICOSTEROIDS for flares (reduce inflammation) - ANTIHISTAMINES (e.g., cetirizine, loratadine) for pruritus relief - Teach: Do NOT scratch — scratching breaks the skin barrier and invites secondary bacterial infection - Use lukewarm water (not hot) for bathing; avoid harsh soaps --- **PSORIASIS** - Chronic AUTOIMMUNE disorder — NOT contagious (very important to teach patients and community) - Mechanism: Accelerated T-cell-mediated epidermal cell turnover — skin cells replicate every 3–4 days instead of the normal 28–30 days - Clinical Features: WELL-DEMARCATED, RAISED, RED PLAQUES covered with SILVERY-WHITE SCALES - Typical locations: Extensor surfaces (elbows, knees), scalp, sacrum, nails (pitting) - Auspitz sign: Pinpoint bleeding when scale is removed - Koebner phenomenon: New plaques appear at sites of skin trauma/injury - Remitting-relapsing course: Periods of flare and periods of remission - Psychosocial burden: Significant impact on self-esteem, social life, and mental health *Management:* - Topical: Corticosteroids (first-line), Vitamin D analogues (calcipotriene), Coal tar preparations, Salicylic acid (keratolytic), Anthralin - Phototherapy: UVB light therapy - Systemic (for severe disease): Methotrexate (folate antagonist; monitor liver function and CBC), Cyclosporine, Biologics (TNF inhibitors like etanercept, IL-17/IL-23 inhibitors) - Nursing Teaching: Psoriasis is CHRONIC and NOT CURABLE but IS MANAGEABLE; address stigma and psychosocial needs --- **CELLULITIS** - Acute bacterial infection of the DERMIS and SUBCUTANEOUS TISSUE - Causative organisms: Usually *Streptococcus pyogenes* and *Staphylococcus aureus* (including MRSA) - Entry: Through a break in the skin (wound, insect bite, tinea pedis, ulcer) - Clinical Features: ERYTHEMA (redness), WARMTH, EDEMA (swelling), TENDERNESS, POORLY DEFINED BORDERS (diffuse, spreading) - May be accompanied by fever, chills, lymphangitis (red streaks), lymphadenopathy - Compare with erysipelas: more superficial, sharply demarcated, raised border *Management:* - SYSTEMIC ANTIBIOTICS: Cephalexin, Dicloxacillin (for non-MRSA); Trimethoprim-sulfamethoxazole or Clindamycin (for MRSA coverage); IV antibiotics if severe - ELEVATE the affected limb to reduce edema - WARM COMPRESSES for comfort - MARK the border of erythema with a pen — assess if redness is spreading or contracting (indicates treatment effectiveness or failure) - Complete the FULL COURSE of antibiotics even if symptoms improve - Return precautions: If redness spreads beyond the marked border or fever spikes, return immediately - Watch for COMPLICATIONS: Abscess formation, bacteremia, NECROTIZING FASCIITIS (rapidly spreading infection with disproportionate pain — surgical emergency) --- **OTHER SKIN INFECTIONS:** *Impetigo:* - Highly contagious superficial skin infection - HONEY-COLORED CRUSTS over erosions - Caused by *S. aureus* and/or *S. pyogenes* - Common in Filipino children, especially in crowded communities - Treatment: Topical mupirocin or fusidic acid; oral antibiotics (amoxicillin-clavulanate, cephalexin) for widespread disease - Strict hygiene; do not share towels and clothing *Herpes Zoster (Shingles):* - Reactivation of VARICELLA-ZOSTER VIRUS (VZV) in a DERMATOME distribution — follows nerve path - Prodrome: 2–4 days of burning, tingling pain BEFORE the rash appears - Rash: Unilateral, dermatomal, painful VESICULAR rash - Most common complication: POSTHERPETIC NEURALGIA (persistent pain after rash heals) - Treatment: ANTIVIRALS — Acyclovir 800 mg 5×/day for 7 days; Valacyclovir or Famciclovir (more bioavailable, fewer doses) - Isolation: CONTACT and AIRBORNE precautions if disseminated or in immunocompromised patients - Pain control: Gabapentin, pregabalin, tricyclic antidepressants for neuropathic pain - Prevention: Zoster vaccine (Shingrix) for adults 50 years and older *Fungal Infections (Tinea, Candidiasis):* - Tinea (ringworm): Caused by dermatophytes; tinea pedis (athlete's foot — sa paa), tinea corporis (body), tinea capitis (scalp), tinea unguium (nails/onychomycosis) - Candidiasis: Caused by *Candida albicans*; common in moist areas (intertriginous folds, oral cavity, vagina) - Risk factors: Diabetes mellitus, immunosuppression, antibiotic use, obesity - Treatment: Topical antifungals (clotrimazole, miconazole, terbinafine) or systemic antifungals (fluconazole, itraconazole) for severe/nail involvement - Keep affected areas DRY; wear breathable clothing; treat underlying risk factors

STEP 1 — Calculate TBSA: Anterior trunk (all partial/full-thickness) = 18%. Arms: Each arm is 9% total, but half of each arm is first-degree (excluded). So each arm contributes 4.5%; both arms = 9%. Anterior legs (partial/full-thickness) = 9% per leg × 2 = 18%. Total TBSA = 18 + 9 + 18 = 45%. STEP 2 — Parkland formula: 4 × 75 × 45 = 13,500 mL Lactated Ringer's. STEP 3 — Timing adjustment: First-half = 6,750 mL. The patient is already 2 hours post-injury; only 6 hours remain in the first 8-hour window. Rate = 6,750 ÷ 6 = 1,125 mL/hr. The second half (6,750 mL) is given over the remaining 16 hours at 422 mL/hr. Monitor urine output: target 0.5 × 75 = 37.5 mL/hr (approximately 30–50 mL/hr).

TBSA: Posterior trunk = 18% (deep partial-thickness — included). Both legs = 18% per leg × 2 = 36% (full-thickness — included). Facial burns need to be classified — if they are superficial (first-degree), they are NOT included. The problem states them as 'facial burns' associated with inhalation injury — even if included as partial-thickness, the singed nasal hairs and hoarseness indicate INHALATION INJURY as the TOP PRIORITY. Per Maslow's hierarchy, airway (physiological — basic survival) takes absolute priority over fluid management. The NANDA diagnoses are ranked: Airway first (safety), then fluid volume (physiological), then pain (physiological-comfort).

At Day 2, capillary integrity is being restored and the previously third-spaced fluid re-enters the circulation — this is the ACUTE PHASE. The large urine output (88–110 mL/hr, far above the 30 mL/hr target) reflects the diuresis of this phase. The nurse should monitor for fluid OVERLOAD (listen for crackles, monitor BP) and adjust IV fluid rate downward. Hypokalemia (K+ 3.1 mEq/L) is expected because: (1) potassium re-enters cells from the extracellular fluid, and (2) large urine output flushes potassium from the body. The nurse should implement ordered potassium replacement, monitor cardiac rhythm (hypokalemia → dysrhythmias), and reassess serum electrolytes regularly.

Silver Sulfadiazine (Silvadene) is known to cause transient leukopenia — a decrease in white blood cell count — in some patients, typically appearing around Days 3–5 of treatment. Crucially, this is differentiated from infection-related leukopenia by the ABSENCE of infection signs (patient is afebrile, wound appears clean). The leukopenia is usually REVERSIBLE upon stopping the medication. The nurse must document and report the CBC findings, assess for signs of infection (which is now a concern with low WBC), and follow the physician's decision regarding continuation or substitution of the topical agent.

In the Philippine community health setting, impetigo is highly common among children in crowded areas. The honey-colored crusts are pathognomonic. It is highly contagious and spreads easily in households and schools. Teaching must emphasize hygiene and isolation of personal items. For the lolo with cellulitis, the combination of diabetes and cellulitis is particularly dangerous because diabetes impairs immune response and wound healing. Marking the border of erythema is a community-level tool nurses can use to monitor progression. Completing antibiotics is critical to prevent recurrence and MRSA development. Both scenarios reflect NCM 103 community health nursing competencies aligned with Philippine primary health care delivery.