Caring for skin and mucus membranes in acutely ill patients. Prepared By : SIG, Dermatology Nursing IADVL

Function of the normal skin Physical Barrier Temperature Regulation Immune Regulation Fluid Retention Vitamin D Synthesis Protection from UV radiation Sensation Excretion of Toxins

Really ill patients Erythroderma SJS, TEN Pustular psoriasis Immunobullous disorders Infections : SSSS, Febrile viral exanthemas

Possible Pathophysiology changes in really ill patients: Hemodynamic changes Impaired thermoregulatory control Metabolic abnormalities Fluid and electrolyte imbalance Loss of nutrients

These pathophysiological changes may lead to: Peripheral edema Pulmonary complications Altered immune functions Infections Persistent inflammation  Vasodilation Increase blood flow  Erythema & Edema High output cardiac failure

These pathophysiological changes may lead to: Increased cutaneous blood flow RadiationHeat loss HYPOTHERMIA Compensatory mechanisms against hypothermia Make up for heat loss Raised BMRShivering Attempt to raise core body temperature Failure to compensate POIKILOTHERMIA Convection

Metabolic abnormalities: Increase BMR Increase BGL and glycosuria Increase amino acid breakdown

Fluid and Electrolyte Imbalance: Normal TEWL= 400 ml/day( ml) In ASF, increase 3-4 times In TEN, 3-4 lit/day Dehydration and decrease urine Low Na+ and high K+ Prerenal uraemia Hypophosphatemia Hypocalcemia

Loss of Nutrients: Protein – Causes: exfoliation,increase BMR,decrease hepatic synthesis,dermatogenic enteropathy,decrease oral intake due to oral lesions. – Normal exfoliation= mg/ day – Increase several folds (9 gm/sq.m./day) – Diffuse scaling- protein loss (20-30 g/sq.m/day) – Psoriasis > Drug Reaction > Eczema – In exudative, gm/ day Iron,Vit. B12 and Folate deficiency.

Peripheral Edema: Increase capillary leakage due to increase levels of circulating VPF and VEGF. Hypoalbuminemia Cardiac failure Inflammation

Pulmonary Complications: Severe pulmonary edema ARDS Aspiration Pneumonia In TEN,dreaded complication

Altered Immune Functions: Impaired chemotaxis and phagocytosis Low serum gamma globulin level In TEN,lymphopenia,neutropenia and thrombocytopenia

Infections: Colonization and systemic entry Septic complications Colonization and systemic entry Septic complications

NoOrgan Involved Complications 1. Eye Ectropion, Entropian, Corneal Scarring, Symblepharon 2. Mucosal InvolvementMucosal Involvement Esophagus Esophagus Dysphagia resulting from stricture Urethra UrethraStricture and phimosisStricture and phimosis Vagina VaginaSynechiae 3. Skin Pigmentary changes, hypohirosis, contracture 4. HairScarring alopeciaScarring alopecia 5. NailBeau’s lines, splinter hemorrhage, distal onycholysis, dystrophy and total shedding of nails Long-term Complications:

General Supportive Treatment: Assessment and Monitoring Fluid and Electrolyte balance Control of infections Temperature control Nutrition

Clinical Biochemica l Hematolo gical Microbiological Pulse rate Respiratory Rate Level of consciousness Urine Output Gastric emptying Blood and Urine Sugar Urea/ creatinin e Serum Elecrolyt es Albumin Phospho rus Total and differe ntial WBC and Platele t count Bacteriology of skin lesions. Urine Culture Assessment and Monitoring :

Fluid and Electrolyte Balance: Fluid of choice = Colloids( Human albumin or FFP), NS Daily Fluid Reqd= Expected TEWL +Urine output. In TEN,Fluid Reqd= 2/3 rd to 3/4 th of burns.

Control of Infections: Local Removal of dead skin Regular bathing Open dressing Silver sulphadiazine Silver nitrate Oil based emollients Control of Infections: Systemic: Indications of Antibiotics High bacterial count Sudden Hypothermia Confused Mental Status Infection Temperature Control: Maintain the Env. Temp at C Antipyretic

Nutrition: In ASF, body can not compensate the energy loss due to reduced appetite, oropharyngeal lesions and malabsorption. Aggressive approach calories in first 3-4 days followed by calories. High protein diet= 2-3 gm/kg body wt/day 3-4 gm/kg body wt/day Vitamins and trace elements

No Underlying Condition Important Causes of Mortality 1. Erythroderma High output cardiac failure  Adult respiratory distress syndrome  Capillary leak syndrome  Sepsis 2. SJS/TEN Massive fluid and electrolyte loss  Prerenal uremia  Septicemia  Pulmonary embolism  Adult respiratory distress syndrome  Gastrointestinal hemorrhage 3. Acute generalized pustular psoriasis Hypocalcemia  Oligemia  Acute tubular necrosis of kidney 4. Pemphigus Septicemia  Fluid and electrolyte imbalance 5. Staphylococcal scalded Skin syndrome Septicemia Causes of Mortality:

Specific Treatment: Specific measures depends on the etiology of the ASF. Conclusion: An entity just as mortal as failure of heart, lungs or kidneys. A dermatological emergency Multi-disciplinary and intensive care approach The earlier it is recognized and treated, the more satisfactory is its outcome. Based on the above facts the Nursing responsibility is highly important in saving the life of the patients specially in following ways: –Care in electrolytes balance –Care in avoiding infections –Care in temperature balance Compulsory part of the curriculum are highlighted in purple.