NLE Integumentary & Skin Integrity — Burns and Dermatologic DisordersSummary

Burns are classified by the number of skin layers destroyed. **Superficial (first-degree) burns** involve only the epidermis, presenting as red, dry, painful skin that blanches with pressure and heals in 3–6 days without scarring (classic example: sunburn). **Superficial partial-thickness (second-degree) burns** extend into the upper dermis, causing blisters, a moist weeping surface, severe pain, and blanching; they typically heal in 2–3 weeks without grafting. **Deep partial-thickness (second-degree) burns** penetrate the deeper dermis, appearing red to waxy white with decreased pain (due to nerve damage), slower capillary refill, and potential need for grafting. **Full-thickness (third-degree) burns** destroy the entire epidermis and dermis, producing a dry, leathery, inelastic eschar colored white, waxy, tan, brown, or charred, with **no pain** (nerve destruction) and no blanching; these **always require skin grafting**. **Fourth-degree burns** extend into muscle, fascia, and bone, often requiring amputation. Understanding burn depth is crucial because it determines healing time, grafting needs, functional outcomes, and risk of complications including contractures and infection.

The **Rule of Nines** provides rapid, accurate estimation of TBSA burned in adults using anatomical regions as multiples of 9%: **Head and neck = 9%** (4.5% anterior + 4.5% posterior), **Each arm = 9%** (4.5% anterior + 4.5% posterior), **Anterior trunk (chest/abdomen) = 18%**, **Posterior trunk (back) = 18%**, **Each leg = 18%** (9% anterior + 9% posterior), **Perineum/genitalia = 1%**. These percentages sum to 100%. **Critical rule: Only partial-thickness and full-thickness burns are counted toward TBSA; superficial (first-degree) burns are excluded from TBSA calculations.** For pediatric patients and more complex burn distributions, the **Lund-Browder chart** provides greater precision because children's proportions differ (larger head). The **palmar method** (patient's palm including fingers ≈ 1% TBSA) is useful for estimating scattered or small burns. Accurate TBSA estimation is the foundation for determining fluid resuscitation volume and predicting systemic complications.

The **Parkland formula** calculates the total intravenous fluid volume needed to prevent hypovolemic shock in the first 24 hours post-burn: **4 mL × body weight (kg) × %TBSA burned = total mL of lactated Ringer's solution for 24 hours**. The critical timing principle divides resuscitation into two phases: **First 8 hours (calculated from time of injury, not time IV started): deliver 50% of the total volume**, and **Next 16 hours: deliver the remaining 50%**. Example: A 70 kg patient with 50% TBSA burns requires 4 × 70 × 50 = 14,000 mL in 24 hours. First 8 hours: 7,000 mL (approximately 875 mL/hr). Next 16 hours: 7,000 mL (approximately 437 mL/hr). **Lactated Ringer's is the fluid of choice** because it replaces electrolytes lost in burn edema and is isotonic. **Adequacy of resuscitation is assessed by urine output, not by strict adherence to formula numbers**: target **0.5 mL/kg/hr (approximately 30–50 mL/hr) in adults** and **1 mL/kg/hr in children**. An indwelling urinary catheter is essential for accurate hourly monitoring. Additional adequacy markers include mean arterial pressure maintenance and clearing sensorium. **Overresuscitation (hyperfluid resuscitation) risks pulmonary edema, abdominal compartment syndrome, and prolonged ventilation**; underresuscitation risks organ failure and death.

The emergent phase begins at the moment of injury and extends 24–48 hours. The defining pathophysiology is **massive fluid shift from the intravascular space into the interstitium ('third spacing')** due to increased capillary permeability from inflammatory mediator release. This causes **hypovolemia (low circulating volume), local and systemic edema, and hemoconcentration (elevated hemoglobin and hematocrit)**. Cellular damage releases **potassium into the extracellular space (hyperkalemia), a life-threatening electrolyte disturbance** that increases risk of cardiac dysrhythmias; conversely, **sodium is trapped in edema fluid, causing hyponatremia**. The greatest threat is **hypovolemic (burn) shock**, manifesting as tachycardia, hypotension, decreased urine output, altered mental status, and poor perfusion. **First priority is the airway**: assess for inhalation injury by inspecting for facial burns, singed nasal hairs, carbonaceous (sooty) sputum, hoarseness, or stridor. If present, give **100% humidified oxygen immediately** and prepare for early intubation because airway edema can progress rapidly and occlude the airway. **Establish large-bore IV access (two lines if possible)** and initiate Parkland formula resuscitation with lactated Ringer's, titrating to urine output. **Insert an indwelling catheter** to monitor hourly output. **Manage pain with IV opioids** (IM/SC routes are unreliable due to edema and poor perfusion; titrate to effect). **Identify circumferential burns** that encircle an extremity or torso, which compromise circulation or breathing; perform **escharotomy (surgical incision through the eschar)** if compartment pressure rises or distal pulses diminish. **Keep the patient NPO** due to risk of paralytic ileus. **Cover wounds with clean, dry dressings** and provide tetanus prophylaxis. Monitor for **rhabdomyolysis** (muscle breakdown) and **myoglobinuria** (dark urine), especially in electrical burns; ensure aggressive hydration to maintain urine output and prevent acute kidney injury.

The acute phase begins when capillary integrity returns, triggering a **fluid shift back into the vascular space (diuresis)**, which reverses hypovolemia but increases risk of **hypervolemia and pulmonary edema if fluids are not reduced**. As intracellular potassium re-enters the bloodstream and is lost in urine, **hyperkalemia reverses to hypokalemia**, requiring careful monitoring and supplementation. **Infection and sepsis become the leading threat**, as the burn wound becomes colonized with bacteria and may progress to invasive infection. Priorities shift to **wound care**: cleansing and debridement (removal of devitalized tissue) at each dressing change, application of topical antimicrobial agents (silver sulfadiazine or mafenide acetate), and dressing selection based on wound characteristics. **Skin grafting** is performed for full-thickness and deep partial-thickness burns once the wound is clean and free of eschar; **autograft** (patient's own skin) is the permanent standard; **allograft** (cadaver skin) or **xenograft** (animal skin) serve as temporary biologic dressings. **Infection prevention** is paramount: use strict aseptic technique, maintain protective isolation if facilities allow, and monitor for sepsis signs (which in burn patients may be subtle: altered mental status, unexplained ileus, temperature instability, hyperglycemia). **Do not use prophylactic systemic antibiotics**; give antibiotics only for documented infection to minimize resistance. **Nutrition is critical**: burns are hypermetabolic (increased caloric expenditure); provide **high-calorie, high-protein nutrition**, often via **enteral feeding started early within 24–48 hours** (improves outcomes, maintains gut barrier, and reduces sepsis risk). Supplement with **vitamin C, vitamin A, and zinc** to support collagen synthesis and immune function. Monitor for **Curling ulcer** (stress-related gastric ulceration), a serious complication; give **prophylactic proton pump inhibitors or H2 blockers**. Begin **positioning and splinting** to prevent contractures: position joints in extension, use splints and soft restraints, and initiate active range-of-motion exercise as tolerated.

The rehabilitation phase begins once wounds are closed (by healing or grafting) and extends for months to years. The focus shifts from survival to **restoring function, mobility, and appearance**. **Contractures (shortening and tightening of connective tissue across joints) are the most common and functionally devastating complication** of burn recovery; prevention is far superior to treatment. **Prevention strategies include positioning joints in extension** (not flexion, which contracts naturally), **splinting and bracing worn 24 hours daily** (or as tolerated), and **early, active range-of-motion exercise**. **Pressure garments** (custom compression suits) are worn 23 hours daily for several months to 1–2 years to reduce hypertrophic (thick, raised) scarring. **Scar management** includes massage, silicone gel sheets, and topical treatments. **Physical and occupational therapy** are essential to regain strength, mobility, and activities of daily living (ADLs). **Psychosocial support** addresses body-image disturbance, depression, anxiety, and post-traumatic stress, which are common; burn survivors often report fear of recurrence, social isolation, and stigma. **Scar maturation takes 12–24 months**; scars may initially be red, raised, and itchy, then gradually fade and flatten. **Family involvement and community reintegration** (returning to work, school, social roles) are crucial for long-term adjustment. In Philippine settings, community health centers and barangay health workers can provide ongoing support and monitoring.

**Electrical burns** cause deceptively deep tissue damage far greater than surface wounds suggest, because electrical current follows the path of least resistance through tissues (often through the heart and nerve pathways). Always monitor for **cardiac dysrhythmias** with cardiac monitoring and obtain an EKG. **Myoglobinuria (dark urine)** indicates rhabdomyolysis; aggressively hydrate (target urine output 1 mL/kg/hr or higher) to prevent **acute kidney injury** from myoglobin precipitation in renal tubules. **Chemical burns** require immediate removal of the chemical agent: **brush off dry powder first**, then **flush with copious amounts of water or saline for 15–20 minutes**; do not attempt neutralization with opposing chemicals, which can generate heat and worsen injury. **Inhalation injury**, suspected with facial burns, singed nasal hairs, carbonaceous sputum, hoarseness, or history of enclosed-space fire, is the **leading cause of early death** in hospitalized burn patients. Give **100% humidified oxygen** immediately and prepare for early intubation before edema progresses. **Circumferential burns** (those encircling an extremity, chest, or abdomen) compromise circulation or breathing; **escharotomy** (surgical incision through the eschar to release tension) is performed if compartment pressures rise or distal perfusion diminishes. **Compartment syndrome** can develop despite escharotomy; if suspected, perform **fasciotomy** (deeper incision through fascia). **Burn shock** in the emergent phase is hypovolemic; **septic shock** in the acute phase results from invasive burn wound infection or other sources.

**Silver sulfadiazine (Silvadene)** is the classic broad-spectrum topical antimicrobial agent for burn wounds. It is effective against gram-positive and gram-negative bacteria and fungi, painless on application, and does not penetrate eschar. **Advantages**: broad spectrum, ease of use, reduced pain. **Disadvantages**: **transient leukopenia** (low white blood cell count) occurs in some patients and usually resolves; **contraindicated in patients with sulfonamide allergy**, **near-term pregnancy**, and **newborns** (risk of kernicterus). **Mafenide acetate (Sulfamylon)** is an alternative topical agent with superior **eschar penetration**, making it useful over cartilage (ears, nose) where silver sulfadiazine may be ineffective. **Advantages**: good eschar penetration. **Disadvantages**: **painful on application** (causing patient distress and limiting its use), and **inhibits carbonic anhydrase, causing metabolic acidosis** with prolonged use (monitor acid-base status and renal function). **Bacitracin** is a topical antibiotic used on minor burns and areas where silver sulfadiazine is contraindicated (e.g., face). **Do not use systemic prophylactic antibiotics** in the acute phase; reserve antibiotics for **documented infection** to avoid selecting for resistant organisms.

**Dermatitis (eczema)** is skin inflammation presenting with **erythema (redness), pruritus (itching), and scaling**. **Contact dermatitis** is a reaction to an irritant (mechanical, chemical, or thermal) or an allergen; it develops after direct contact with the offending agent and improves when contact is avoided. **Atopic dermatitis (allergic eczema)** is a **chronic inflammatory condition** associated with a genetic predisposition to allergies, asthma, and allergic rhinitis; it often begins in infancy or childhood and may persist into adulthood. Patients have impaired skin barrier function (reduced ceramides and filaggrin), making skin dry, sensitive, and prone to colonization with *Staphylococcus aureus*. **Nursing management** includes: identifying and **avoiding triggers** (irritants, allergens, stress, extreme temperatures, harsh soaps), **frequent use of emollients and moisturizers** (apply within 3 minutes of bathing to trap water), **topical corticosteroids** (low potency for face/skin folds; higher potency for thick, scaly areas) for acute flares, **topical calcineurin inhibitors** (tacrolimus, pimecrolimus) as steroid-sparing agents, **antihistamines** (oral, e.g., cetirizine, diphenhydramine) for itch relief, and **teaching to avoid scratching** (scratching breaks the skin barrier, invites secondary infection, and perpetuates the itch-scratch cycle). Referral to an allergist for patch testing may identify specific contact allergens. In the Philippine context, counsel patients about local environmental triggers (humidity, pollution, dust mites) and affordability of emollients.

**Psoriasis** is a **chronic, autoimmune inflammatory skin disorder** characterized by accelerated epidermal cell turnover (keratinocytes proliferate 8–10 times faster than normal). This results in **well-demarcated, raised, red plaques covered with silvery-white, micaceous scales**, most commonly on the **extensor surfaces (elbows, knees, sacrum, scalp)**. **Psoriasis is NOT contagious**; it is a lifelong, remitting-relapsing condition triggered by stress, infection (especially streptococcal pharyngitis), medications (beta-blockers, lithium, NSAIDs), trauma, and environmental factors. **Nursing management** includes: **Topical corticosteroids** (first-line for mild-to-moderate disease; taper as symptoms improve to prevent skin atrophy), **vitamin D analogues** (calcipotriene, calcitrol), which normalize epidermal differentiation, **coal tar** preparations (older agent, effective but messy), **phototherapy** (narrowband UVB light, the gold standard for moderate-to-severe disease), and for **severe plaque psoriasis and systemic disease**, systemic agents including **methotrexate**, **acitretin**, and **biologic agents** (TNF-alpha inhibitors like infliximab, etanercept; IL-17 and IL-23 inhibitors). **Teach patients that psoriasis is a lifelong condition, not a cure-and-forget disease**; explain the role of stress management, avoiding triggers, and adhering to treatment regimens. **Address the psychosocial burden**: psoriasis often causes body-image disturbance, depression, and social withdrawal; encourage support groups and counseling. **Monitor for systemic complications**: psoriatic arthritis (10–15% of patients), cardiovascular disease, metabolic syndrome, and depression. In Philippine settings, acknowledge the affordability of medications and explore locally available phototherapy options.

**Cellulitis** is an acute **bacterial infection of the dermis and subcutaneous tissue**, most commonly caused by **Streptococcus pyogenes (Group A Streptococcus) or Staphylococcus aureus**, including methicillin-resistant *S. aureus* (MRSA). Bacteria enter through breaks in the skin (cuts, abrasions, surgical wounds, insect bites). **Clinical presentation** includes: **erythema (redness), warmth, edema, and tenderness** with **poorly defined (diffuse) borders** (distinguishing it from localized abscess); sometimes **fever, chills, and lymphangitic streaking** (red lines tracking toward regional lymph nodes). **Risk factors** include diabetes, venous/lymphatic insufficiency, obesity, and immunosuppression. **Nursing management** includes: **Systemic antibiotics** (e.g., cephalexin, dicloxacillin; add MRSA coverage with trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin if MRSA risk is high) for 7–14 days; **elevation** of the affected limb to reduce edema, **warm compresses** for comfort, and **analgesia**. **Mark the border of erythema with a pen** and have the patient mark the time; this allows objective assessment of progression or resolution (if erythema stays within the line or recedes, treatment is working; if it spreads beyond the mark, infection is progressing and may require IV antibiotics or hospitalization). **Teach completion of the full antibiotic course** to prevent resistance and relapse. **Watch for escalation to sepsis** (hypotension, tachycardia, altered mental status, lactic acidosis) or **necrotizing fasciitis** (rapidly spreading infection of deeper fascia, with severe pain, systemic toxicity, and high mortality); these are medical emergencies. **Prevention** includes wound care, prompt treatment of minor skin injuries, and hygiene.

**Impetigo** is a **superficial bacterial infection** caused by *Streptococcus pyogenes* or *Staphylococcus aureus*, highly contagious, and common in children. It presents with **honey-colored crusts** (streptococcal) or **nonbullous crusted lesions** (staphylococcal); may begin as vesicles that quickly rupture. **Management**: **topical or oral antibiotics** (topical mupirocin for localized disease; oral cephalexin or amoxicillin-clavulanate for extensive disease), **gentle cleansing**, and **strict hygiene** to prevent spread to other body areas or other people. **Herpes zoster (shingles)** is **reactivation of varicella-zoster virus (VZV)** that lies dormant in dorsal root ganglia after chickenpox; it presents along a **dermatomal distribution** with a **painful vesicular rash** that is often preceded by burning pain (prodrome). Common in older adults and immunocompromised patients. **Management**: **systemic antivirals** (acyclovir, valacyclovir, famciclovir) within 72 hours of rash onset to reduce viral shedding and complications; **pain control** (important, as post-herpetic neuralgia is a painful long-term consequence); **contact/airborne precautions** in hospitalized patients, especially if disseminated or immunocompromised; **cool compresses and topical agents** (calamine lotion) for comfort. **Prevention of VZV transmission to susceptible individuals** is critical (varicella vaccine for unvaccinated contacts, avoiding contact with lesions). **Fungal infections (tinea pedis, tinea corporis, tinea cruris, candidiasis)** present with scaling, erythema, and pruritus in characteristic locations (tinea pedis: feet; tinea corporis: body; tinea cruris: groin). **Management**: **topical antifungals** (miconazole, terbinafine, clotrimazole) for localized disease; **systemic antifungals** (fluconazole, griseofulvin) for extensive or nail involvement; **keep the area dry** (moisture promotes fungal growth); **teach prevention** (dry skin thoroughly after bathing, avoid sharing towels/nail tools, wear breathable footwear).

**NANDA-I nursing diagnoses** relevant to burns and dermatologic disorders align with **Maslow's hierarchy of needs**, guiding prioritization: **Physiologic needs (foundation)**: Deficient fluid volume (emergent phase), Decreased cardiac output, Ineffective airway clearance (if inhalation injury), Acute pain, Impaired skin integrity, Imbalanced nutrition (less than body requirements), Risk for infection, Risk for complications (Curling ulcer, compartment syndrome, sepsis), and Hyperthermia. **Safety needs**: Risk for fall, Risk for injury (from immobility, contractures), and Infection control measures. **Love and belonging**: Interrupted family processes, Social isolation (especially in rehabilitation phase). **Esteem**: Body-image disturbance, Situational low self-esteem (post-burn, particularly if visible scarring). **Self-actualization**: Readiness for enhanced coping, Community reintegration. **RA 9173 Scope of Practice**: The Philippine Nursing Practice Act empowers nurses to conduct comprehensive health assessment, formulate nursing diagnoses, plan and implement nursing interventions (including wound care, medication administration, patient education), and evaluate patient outcomes. Nurses collaborate with physicians on medical diagnoses and treatment plans. **In the context of burns and dermatologic disorders, nurses serve as the primary advocate for skin integrity, infection prevention, comfort, and psychosocial support**, leveraging the therapeutic nurse-patient relationship central to Filipino nursing values.

**Burn prevention** is the most effective intervention; nurses educate the public on: **smoke detectors** (functional in bedrooms and living areas), **safe water heater temperature** (set below 49°C/120°F to prevent scalds, especially in households with children and elderly), **kitchen safety** (keep flammable items away from stovetops, use pot handles turned inward, wear fitted clothing while cooking), **electrical safety** (inspect cords, avoid overloaded outlets, keep electricity away from water), and **fire extinguishers and escape routes**. **For acute burn care adherence**: teach the importance of **completing antibiotic courses**, **attending wound care appointments**, **adhering to pressure garment and splinting therapy** (which are uncomfortable and inconvenient but critical for preventing contractures), and **recognizing signs of infection** (increased warmth, redness, drainage, fever) and returning immediately if present. **For chronic dermatologic conditions**: emphasize that **psoriasis and eczema are manageable but not curable**; teach **trigger avoidance**, **correct topical application** (e.g., apply emollients while skin is damp), and the **importance of consistency and patience** (improvements take weeks). **Psychosocial support** is essential: burn survivors often experience **post-traumatic stress, depression, anxiety, and grief** related to body-image changes, loss of function, and fear of recurrence; nurses **normalize these feelings, provide listening presence, and refer to mental health services**. **Family involvement** accelerates healing and prevents isolation; teach families about wound care, infection signs, and how to support the patient's emotional recovery. In the **Philippine context**, acknowledge cultural values of family interdependence, involve extended family in care planning, and connect patients with community health workers and **barangay health centers** for ongoing support.

Superficial (first-degree) burns heal spontaneously in 3–6 days without scarring and are very painful; superficial partial-thickness burns take 2–3 weeks and are extremely painful; deep partial-thickness burns may require grafting and scar; full-thickness burns always require grafting and are painless. This relationship guides both immediate pain management and long-term reconstruction planning.

Accurate TBSA (using Rule of Nines, excluding first-degree burns) is the foundation for calculating fluid resuscitation volume. Larger TBSA correlates with greater hypovolemic shock risk, greater fluid third-spacing, and greater systemic inflammatory response. This relationship drives triage decisions (burns ≥15–20% TBSA in adults typically require specialized burn center care).

The Parkland formula provides an initial calculation, but the critical principle is timing the first 50% within the first 8 hours from the time of injury (not from arrival or IV start). Hourly urine output (target 0.5–1 mL/kg/hr) is the best indicator of adequate perfusion; if urine output is low, fluid rate is increased; if urine output is high, fluid rate is decreased. This demonstrates that the formula is a guide, not a rigid protocol.

Massive fluid shift into the interstitium causes hypovolemia, edema, and hemoconcentration; potassium release causes hyperkalemia. These pathophysiologic changes necessitate emergent airway management (if inhalation injury is suspected), large-bore IV access, aggressive Parkland resuscitation, hourly urine monitoring, and cardiac monitoring for dysrhythmias. This relationship explains why the emergent phase is the highest-acuity period.

In the emergent phase, fluid is maximized to prevent shock; in the acute phase, fluid is decreased because diuresis reverses hypovolemia (risk of pulmonary edema). In the emergent phase, infection is unlikely; in the acute phase, infection is the leading threat, driving wound care, topical antimicrobials, early nutrition, and sepsis surveillance. This relationship illustrates the dynamic nature of burn management across phases.

Contractures result from unopposed flexor muscle contraction and connective tissue shortening. Prevention is far superior to treatment and begins in the acute phase with positioning in extension, splinting, and gentle ROM. Continued vigilance in the rehabilitation phase with pressure garments, continued splinting, and aggressive PT/OT prevents the most common late complication and preserves function and appearance.

Silver sulfadiazine is broad-spectrum, painless, and good for most burns, but does NOT penetrate eschar; it is contraindicated in sulfa allergy. Mafenide acetate penetrates eschar (useful on cartilage), but is painful and causes metabolic acidosis. The choice reflects clinical judgment about wound depth, location, and patient factors, not a one-size-fits-all approach.

In the emergent phase, pain and physiologic needs dominate. In the acute phase, body-image concerns and depression emerge as the patient becomes aware of the extent of injury. In the rehabilitation phase, returning to family, work, and social roles becomes central, and PTSD, anxiety, and grief may intensify. Psychosocial interventions must be phase-appropriate and culturally sensitive.

RA 9173 empowers nurses to educate patients and families. Teaching burn prevention (smoke detectors, safe water temperature) can prevent tragedy. Teaching medication and wound care adherence improves outcomes. Teaching psoriasis/eczema trigger avoidance and treatment consistency empowers long-term self-management. This relationship shows that nursing extends beyond acute care into community health and health promotion.

In the emergent phase, physiologic diagnoses (Deficient fluid volume, Acute pain, Risk for airway obstruction) are first priority. In the acute phase, Infection and Impaired skin integrity become paramount. In the rehabilitation phase, Body-image disturbance and Social isolation rise in priority. This relationship ensures that nursing care is person-centered and holistic, not just task-focused.

Suspected inhalation injury (facial burns, singed hairs, soot, stridor) mandates immediate 100% humidified oxygen and early intubation planning because airway edema progresses rapidly and can suddenly occlude the airway, leading to death. Delayed recognition of inhalation injury is a preventable cause of early burn mortality. This relationship emphasizes the critical importance of early assessment and intervention.

Electrical burns require cardiac monitoring and aggressive hydration (for rhabdomyolysis prevention). Chemical burns require immediate removal of the agent and copious flushing. These specific pathophysiologies and interventions differ from thermal burns and must be recognized and managed appropriately. Missing the diagnosis leads to delayed treatment and complications.

Cellulitis is a diffuse bacterial infection; abscess is localized and purulent. Cellulitis requires systemic antibiotics; abscess requires drainage ± antibiotics. Psoriasis is autoimmune, not infectious, and does not respond to antibiotics. Nurses must differentiate these conditions based on clinical presentation to guide appropriate management and prevent unnecessary interventions or missed diagnoses.