Question

Ms. Jackson, a 37-year-old patient, was told by the doctor to clean, pat and cover her wound with a disinfectant cleaner. She went home and cleaned the wound with household bleach and used toilet paper, napkins and old rags to cover the wound. After cleaning the wound with the bleach, Ms. Jackson suffered a second degree chemical burn and developed an infection. Nursing diagnosis SMART Goal 3 interventions

Answer 1

Ans) Impaired Skin Integrity:Altered epidermis and/or dermis.

May be related to:

- Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting

Possibly evidenced by:

Absence of viable tissue

Desired Outcomes

Wound Healing: Secondary Intention (NOC)

Demonstrate tissue regeneration.

Achieve timely healing of burned areas.

Nursing Interventions & Rationale:

Nursing Assessment

Assess and document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin. Provides baseline information about need for skin grafting and possible clues about circulation in area to support graft.

Therapeutic Interventions:

- Provide appropriate burn care and infection control measures. Prepares tissues for grafting and reduces risk of infection/graft failure.

Maintain wound covering as indicated

- Biosynthetic dressing (Biobrane)

Nylon fabric and/or silicon membrane containing collagenous porcine peptides that adheres to wound surface until removed or sloughed off by spontaneous skin reepithelialization. Useful for eschar-free partial-thickness burns awaiting autografts because it can remain in place 2–3 wk or longer and is permeable to topical antimicrobial agents.

- Synthetic dressings: DuoDerm

Hydroactive dressing that adheres to the skin to cover small partial-thickness burns and that interacts with wound exudate to form a soft gel that facilitates debridement.

- Opsite, Acuderm

Thin, transparent, elastic, waterproof, occlusive dressing (permeable to moisture and air) that is used to cover clean partial-thickness wounds and clean donor sites.

Reduces swelling/limits risk of graft separation.

- Elevate grafted area if possible. Maintain desired position and immobility of area when indicated. Movement of tissue under graft can dislodge it, interfering with optimal healing.

- Maintain dressings over newly grafted area and/or donor site as indicated: mesh, petroleum, nonadhesive. Areas may be covered by translucent, nonreactive surface material (between graft and outer dressing) to eliminate shearing of new epithelium and protect healing tissue. The donor site is usually covered for 4–24 hr, then bulky dressings are removed and fine mesh gauze is left in place.

Keep skin free from pressure Promotes circulation and prevents ischemia or necrosis and graft failure.

Evaluate color of grafted and donor site(s); note presence or absence of healing. Evaluates effectiveness of circulation and identifies developing complications.

Wash sites with mild soap, rinse, and lubricate with cream several times daily after dressings are removed and healing is accomplished. Newly grafted skin and healed donor sites require special care to maintain flexibility.

Aspirate blebs under sheet grafts with sterile needle or roll with sterile swab. Fluid-filled blebs prevent graft adherence to underlying tissue, increasing risk of graft failure.

- Prepare for/assist with surgical grafting or biological dressings:

Homograft (allograft)

Skin grafts obtained from living persons or cadavers are used as a temporary covering for extensive burns until person’s own skin is ready for grafting (test graft), to cover excised wounds immediately after escharotomy, or to protect granulation tissue.

Heterograft (xenograft, porcine)

Skin grafts may be carried out with animal skin for the same purposes as homografts or to cover meshed autografts.

- CulturedCultured epithelial autograft (CEA)

Skin graft obtained from uninjured part of patient’s own skin and prepared in a laboratory; may be full-thickness or partial-thickness. Note: This process takes 20–30 days from harvest to application. The new CEA sheets are 1–6 cell layers thick and thus are very fragile.

Artificial skin (Integra)

Wound covering approved by the Food and Drug Administration (FDA) for full-thickness and deep partial-thickness burns. It provides a permanent, immediate covering that reproduces the skin’s normal functions and stimulates the regeneration of dermal tissue.