Integumentary

Surgical drains remove fluid or blood from a wound or cavity to prevent collection, which would impair healing and provide a medium for infection. Open systems such as the Penrose drain are soft tubes draining by gravity and capillary action into an absorbent dressing; they have no collection chamber, dressings are changed frequently, and a sterile safety pin is placed to prevent the drain retracting into the wound, repositioned when the drain is shortened on the provider's instruction. Closed systems such as the Hemovac and Jackson-Pratt collect into a chamber under negative pressure created by compressing the device after emptying — recompression is essential, since an expanded chamber exerts no suction. Chest drains are a distinct closed system with their own management. For all drains, the nurse records volume, color and character each shift, secures the tubing to prevent traction, keeps the collection device below the site, inspects the insertion site for redness and leakage, and maintains asepsis when emptying. Expected drainage is serosanguineous initially, decreasing in volume and becoming serous over days. Increasing volume, a change to bright red, or purulent or malodorous drainage are reported.

Burn depth is classified by which skin layer is destroyed, and sensation is preserved only while dermal nerve endings survive.

Impetigo is a superficial bacterial infection, usually staphylococcal or streptococcal, that takes hold where the skin barrier is already broken — a scratch, an insect bite, or eczema. It produces vesicles that rupture and dry into a characteristic honey-colored crust, and that crust is the practical problem: it forms a physical barrier over the site of bacterial growth, so topical treatment applied on top of it does little. Soaking or washing to soften and lift it first is therefore part of the treatment. Warmth and moisture favor the organism, which is why lesions are left open rather than occluded. Transmission is by direct contact with the exudate or with contaminated items, so hand hygiene, separate towels and bedding, and keeping the child away from close contact until healing are the core family teaching.

Staples and sutures are removed once healing is sufficient, generally around seven to fourteen days depending on site, tension and the client's healing capacity — earlier on the face, later over joints and in clients with impaired healing from diabetes, corticosteroids, malnutrition or obesity. Assessment precedes removal: the incision should be well approximated with no signs of infection and no separation. Where either is present, removal is deferred and the provider contacted. Removal is a clean rather than sterile procedure in most protocols. The staple extractor's lower jaw is placed fully beneath the staple and the handles squeezed to bend it, which releases both ends together; the staple is then lifted straight out. Alternate staples are removed first with adhesive closure strips applied, and the remainder taken only if the wound holds. Sutures are removed by cutting close to the skin on one side and pulling toward the wound so that no portion of suture that was outside the body passes through the tissue. Clients are taught to keep closure strips in place until they fall off, to watch for separation, and to report increasing pain, redness or drainage.

Wound dressings are selected by wound bed appearance, exudate level, depth, presence of infection and the goal of care. Moist wound healing is the governing principle: a moist bed supports epithelial migration and autolytic debridement, while desiccation produces eschar that impedes it — so the traditional advice to keep wounds dry and exposed has been superseded. Transparent films are semi-permeable, non-absorbent, allow inspection without removal, and suit superficial wounds with minimal exudate. Hydrocolloids are occlusive, maintain moisture, support autolytic debridement and may remain several days. Hydrogels donate moisture to dry wounds. Foams absorb moderate to heavy exudate and cushion. Alginates, derived from seaweed, absorb heavy exudate and form a gel, and are also hemostatic. Antimicrobial dressings including silver preparations are used for colonized or infected wounds. Wet-to-dry gauze is a mechanical, non-selective debridement method that removes viable tissue along with devitalized tissue and is painful, so it has largely been replaced by autolytic, enzymatic or sharp debridement. Negative pressure therapy is used for large or complex wounds.

Pressure injury prevention is largely delegable; pressure injury assessment is not. Turning to a written schedule, offloading heels, keeping skin clean and dry, and reporting what is seen are high-value tasks for an assistant. Whether erythema blanches distinguishes transient reactive hyperemia from a stage 1 pressure injury, which is a staging decision; sterile dressing change involves assessing the wound bed; and matching a dressing to exudate is a clinical choice. All three require the person performing them to interpret findings, so all three stay with the nurse.

A sterile field must be kept in continuous view, because the assurance of sterility comes from observation and nothing else. Once a field has been left unattended, the basis for calling it sterile has gone, and no subsequent inspection can restore it — contamination is not visible. The same principle underlies the other rules of asepsis: sterile touches only sterile, the field is set up as close as possible to the time of use, and the nurse faces the field at all times. Re-establishing the field with new supplies is the only correct response.

Repositioning works by moving the load onto tissue that can bear it, so the position chosen matters as much as the frequency. A 30-degree lateral tilt distributes weight across the soft tissue of the buttock, while a full 90-degree side-lying position concentrates it over the greater trochanter — bone with very little covering and a common site of pressure injury. A pillow between the knees prevents bony contact, heels are offloaded from the surface entirely, and the head of the bed is kept as low as the client's condition allows, because elevation above about 30 degrees produces shear over the sacrum. Shear and moisture compound pressure.

A pressure injury forms when sustained pressure over a bony prominence exceeds capillary filling pressure, cutting off blood supply until the tissue dies. Time and pressure trade off against each other — high pressure for a short period or low pressure for a long one both cause damage. Shear compounds it: when a client slides down the bed, skin stays put while the skeleton moves, tearing the vessels between. Moisture weakens the skin's barrier, and poor protein intake removes the raw material for repair. Prevention therefore attacks all four: relieve pressure, avoid shear, keep skin dry, and feed the tissue.

Pressure injuries are staged by the depth of tissue loss. Stage 1 is intact skin with non-blanchable erythema, which may be preceded by changes in temperature, firmness or sensation and is harder to detect in darker skin, where color change may appear purple or maroon rather than red. Stage 2 is partial-thickness loss of dermis, presenting as a shallow open ulcer with a red-pink bed, or as an intact or ruptured blister; there is no slough, and no fat or deeper structure is visible. Stage 3 is full-thickness loss with subcutaneous fat visible, possibly with slough, undermining or tunneling, and depth varies by site since areas such as the ear and malleolus have little subcutaneous tissue. Stage 4 is full-thickness loss exposing bone, tendon or muscle. Unstageable means the base is obscured by slough or eschar, and it is staged once cleared — with the exception of stable dry eschar on an ischemic heel, which is left intact as a biological cover. Deep tissue pressure injury is persistent non-blanchable deep red, maroon or purple discoloration, or a blood-filled blister, indicating damage beneath intact skin.

Wound dressings are selected by wound bed appearance, exudate level, depth, presence of infection and the goal of care. Moist wound healing is the governing principle: a moist bed supports epithelial migration and autolytic debridement, while desiccation produces eschar that impedes it — so the traditional advice to keep wounds dry and exposed has been superseded. Transparent films are semi-permeable, non-absorbent, allow inspection without removal, and suit superficial wounds with minimal exudate. Hydrocolloids are occlusive, maintain moisture, support autolytic debridement and may remain several days. Hydrogels donate moisture to dry wounds. Foams absorb moderate to heavy exudate and cushion. Alginates, derived from seaweed, absorb heavy exudate and form a gel, and are also hemostatic. Antimicrobial dressings including silver preparations are used for colonized or infected wounds. Wet-to-dry gauze is a mechanical, non-selective debridement method that removes viable tissue along with devitalized tissue and is painful, so it has largely been replaced by autolytic, enzymatic or sharp debridement. Negative pressure therapy is used for large or complex wounds.

Pressure injury prevention is largely delegable; pressure injury assessment is not. Turning to a written schedule, offloading heels, keeping skin clean and dry, and reporting what is seen are high-value tasks for an assistant. Whether erythema blanches distinguishes transient reactive hyperemia from a stage 1 pressure injury, which is a staging decision; sterile dressing change involves assessing the wound bed; and matching a dressing to exudate is a clinical choice. All three require the person performing them to interpret findings, so all three stay with the nurse.

Surgical drains remove fluid or blood from a wound or cavity to prevent collection, which would impair healing and provide a medium for infection. Open systems such as the Penrose drain are soft tubes draining by gravity and capillary action into an absorbent dressing; they have no collection chamber, dressings are changed frequently, and a sterile safety pin is placed to prevent the drain retracting into the wound, repositioned when the drain is shortened on the provider's instruction. Closed systems such as the Hemovac and Jackson-Pratt collect into a chamber under negative pressure created by compressing the device after emptying — recompression is essential, since an expanded chamber exerts no suction. Chest drains are a distinct closed system with their own management. For all drains, the nurse records volume, color and character each shift, secures the tubing to prevent traction, keeps the collection device below the site, inspects the insertion site for redness and leakage, and maintains asepsis when emptying. Expected drainage is serosanguineous initially, decreasing in volume and becoming serous over days. Increasing volume, a change to bright red, or purulent or malodorous drainage are reported.

Staples and sutures are removed once healing is sufficient, generally around seven to fourteen days depending on site, tension and the client's healing capacity — earlier on the face, later over joints and in clients with impaired healing from diabetes, corticosteroids, malnutrition or obesity. Assessment precedes removal: the incision should be well approximated with no signs of infection and no separation. Where either is present, removal is deferred and the provider contacted. Removal is a clean rather than sterile procedure in most protocols. The staple extractor's lower jaw is placed fully beneath the staple and the handles squeezed to bend it, which releases both ends together; the staple is then lifted straight out. Alternate staples are removed first with adhesive closure strips applied, and the remainder taken only if the wound holds. Sutures are removed by cutting close to the skin on one side and pulling toward the wound so that no portion of suture that was outside the body passes through the tissue. Clients are taught to keep closure strips in place until they fall off, to watch for separation, and to report increasing pain, redness or drainage.

Wound dressings are selected by wound bed appearance, exudate level, depth, presence of infection and the goal of care. Moist wound healing is the governing principle: a moist bed supports epithelial migration and autolytic debridement, while desiccation produces eschar that impedes it — so the traditional advice to keep wounds dry and exposed has been superseded. Transparent films are semi-permeable, non-absorbent, allow inspection without removal, and suit superficial wounds with minimal exudate. Hydrocolloids are occlusive, maintain moisture, support autolytic debridement and may remain several days. Hydrogels donate moisture to dry wounds. Foams absorb moderate to heavy exudate and cushion. Alginates, derived from seaweed, absorb heavy exudate and form a gel, and are also hemostatic. Antimicrobial dressings including silver preparations are used for colonized or infected wounds. Wet-to-dry gauze is a mechanical, non-selective debridement method that removes viable tissue along with devitalized tissue and is painful, so it has largely been replaced by autolytic, enzymatic or sharp debridement. Negative pressure therapy is used for large or complex wounds.

A sterile field must be kept in continuous view, because the assurance of sterility comes from observation and nothing else. Once a field has been left unattended, the basis for calling it sterile has gone, and no subsequent inspection can restore it — contamination is not visible. The same principle underlies the other rules of asepsis: sterile touches only sterile, the field is set up as close as possible to the time of use, and the nurse faces the field at all times. Re-establishing the field with new supplies is the only correct response.

A pressure injury forms when sustained pressure over a bony prominence exceeds capillary filling pressure, cutting off blood supply until the tissue dies. Time and pressure trade off against each other — high pressure for a short period or low pressure for a long one both cause damage. Shear compounds it: when a client slides down the bed, skin stays put while the skeleton moves, tearing the vessels between. Moisture weakens the skin's barrier, and poor protein intake removes the raw material for repair. Prevention therefore attacks all four: relieve pressure, avoid shear, keep skin dry, and feed the tissue.

Impetigo is a superficial bacterial infection, usually staphylococcal or streptococcal, that takes hold where the skin barrier is already broken — a scratch, an insect bite, or eczema. It produces vesicles that rupture and dry into a characteristic honey-colored crust, and that crust is the practical problem: it forms a physical barrier over the site of bacterial growth, so topical treatment applied on top of it does little. Soaking or washing to soften and lift it first is therefore part of the treatment. Warmth and moisture favor the organism, which is why lesions are left open rather than occluded. Transmission is by direct contact with the exudate or with contaminated items, so hand hygiene, separate towels and bedding, and keeping the child away from close contact until healing are the core family teaching.

Pressure injuries are staged by the depth of tissue loss. Stage 1 is intact skin with non-blanchable erythema, which may be preceded by changes in temperature, firmness or sensation and is harder to detect in darker skin, where color change may appear purple or maroon rather than red. Stage 2 is partial-thickness loss of dermis, presenting as a shallow open ulcer with a red-pink bed, or as an intact or ruptured blister; there is no slough, and no fat or deeper structure is visible. Stage 3 is full-thickness loss with subcutaneous fat visible, possibly with slough, undermining or tunneling, and depth varies by site since areas such as the ear and malleolus have little subcutaneous tissue. Stage 4 is full-thickness loss exposing bone, tendon or muscle. Unstageable means the base is obscured by slough or eschar, and it is staged once cleared — with the exception of stable dry eschar on an ischemic heel, which is left intact as a biological cover. Deep tissue pressure injury is persistent non-blanchable deep red, maroon or purple discoloration, or a blood-filled blister, indicating damage beneath intact skin.

Burn depth is classified by which skin layer is destroyed, and sensation is preserved only while dermal nerve endings survive.

Major burns produce a systemic inflammatory response with dramatically increased capillary permeability, so plasma leaves the intravascular space into the interstitium, producing burn shock, hypovolemia and massive edema. Fluid resuscitation replaces that loss and is calculated from body weight and the percentage of total body surface area burned, using a formula such as Parkland with lactated Ringer's solution, of which half is given in the first eight hours measured from the time of injury rather than from presentation, and the remainder over the following sixteen. Formulas are a starting point only, and the infusion is titrated against response, with urine output the primary endpoint — around 0.5 mL/kg/hour in adults and somewhat higher in children — alongside mental status, heart rate and lactate. Over-resuscitation carries its own harm, including compartment syndrome, pulmonary edema and prolonged ventilation. Other early priorities are airway assessment, since inhalation injury may progress to obstruction and early intubation is safer than late; escharotomy where circumferential burns restrict circulation or chest expansion; analgesia; temperature maintenance, since burned skin loses heat rapidly; and tetanus prophylaxis.

Repositioning works by moving the load onto tissue that can bear it, so the position chosen matters as much as the frequency. A 30-degree lateral tilt distributes weight across the soft tissue of the buttock, while a full 90-degree side-lying position concentrates it over the greater trochanter — bone with very little covering and a common site of pressure injury. A pillow between the knees prevents bony contact, heels are offloaded from the surface entirely, and the head of the bed is kept as low as the client's condition allows, because elevation above about 30 degrees produces shear over the sacrum. Shear and moisture compound pressure.

A pressure injury forms when sustained pressure over a bony prominence exceeds capillary filling pressure, cutting off blood supply until the tissue dies. Time and pressure trade off against each other — high pressure for a short period or low pressure for a long one both cause damage. Shear compounds it: when a client slides down the bed, skin stays put while the skeleton moves, tearing the vessels between. Moisture weakens the skin's barrier, and poor protein intake removes the raw material for repair. Prevention therefore attacks all four: relieve pressure, avoid shear, keep skin dry, and feed the tissue.

Pressure injury prevention is largely delegable; pressure injury assessment is not. Turning to a written schedule, offloading heels, keeping skin clean and dry, and reporting what is seen are high-value tasks for an assistant. Whether erythema blanches distinguishes transient reactive hyperemia from a stage 1 pressure injury, which is a staging decision; sterile dressing change involves assessing the wound bed; and matching a dressing to exudate is a clinical choice. All three require the person performing them to interpret findings, so all three stay with the nurse.

Major burns produce a systemic inflammatory response with dramatically increased capillary permeability, so plasma leaves the intravascular space into the interstitium, producing burn shock, hypovolemia and massive edema. Fluid resuscitation replaces that loss and is calculated from body weight and the percentage of total body surface area burned, using a formula such as Parkland with lactated Ringer's solution, of which half is given in the first eight hours measured from the time of injury rather than from presentation, and the remainder over the following sixteen. Formulas are a starting point only, and the infusion is titrated against response, with urine output the primary endpoint — around 0.5 mL/kg/hour in adults and somewhat higher in children — alongside mental status, heart rate and lactate. Over-resuscitation carries its own harm, including compartment syndrome, pulmonary edema and prolonged ventilation. Other early priorities are airway assessment, since inhalation injury may progress to obstruction and early intubation is safer than late; escharotomy where circumferential burns restrict circulation or chest expansion; analgesia; temperature maintenance, since burned skin loses heat rapidly; and tetanus prophylaxis.

Pressure injury prevention is largely delegable; pressure injury assessment is not. Turning to a written schedule, offloading heels, keeping skin clean and dry, and reporting what is seen are high-value tasks for an assistant. Whether erythema blanches distinguishes transient reactive hyperemia from a stage 1 pressure injury, which is a staging decision; sterile dressing change involves assessing the wound bed; and matching a dressing to exudate is a clinical choice. All three require the person performing them to interpret findings, so all three stay with the nurse.

Impetigo is a superficial bacterial infection, usually staphylococcal or streptococcal, that takes hold where the skin barrier is already broken — a scratch, an insect bite, or eczema. It produces vesicles that rupture and dry into a characteristic honey-colored crust, and that crust is the practical problem: it forms a physical barrier over the site of bacterial growth, so topical treatment applied on top of it does little. Soaking or washing to soften and lift it first is therefore part of the treatment. Warmth and moisture favor the organism, which is why lesions are left open rather than occluded. Transmission is by direct contact with the exudate or with contaminated items, so hand hygiene, separate towels and bedding, and keeping the child away from close contact until healing are the core family teaching.

Major burns produce a systemic inflammatory response with dramatically increased capillary permeability, so plasma leaves the intravascular space into the interstitium, producing burn shock, hypovolemia and massive edema. Fluid resuscitation replaces that loss and is calculated from body weight and the percentage of total body surface area burned, using a formula such as Parkland with lactated Ringer's solution, of which half is given in the first eight hours measured from the time of injury rather than from presentation, and the remainder over the following sixteen. Formulas are a starting point only, and the infusion is titrated against response, with urine output the primary endpoint — around 0.5 mL/kg/hour in adults and somewhat higher in children — alongside mental status, heart rate and lactate. Over-resuscitation carries its own harm, including compartment syndrome, pulmonary edema and prolonged ventilation. Other early priorities are airway assessment, since inhalation injury may progress to obstruction and early intubation is safer than late; escharotomy where circumferential burns restrict circulation or chest expansion; analgesia; temperature maintenance, since burned skin loses heat rapidly; and tetanus prophylaxis.

A sterile field must be kept in continuous view, because the assurance of sterility comes from observation and nothing else. Once a field has been left unattended, the basis for calling it sterile has gone, and no subsequent inspection can restore it — contamination is not visible. The same principle underlies the other rules of asepsis: sterile touches only sterile, the field is set up as close as possible to the time of use, and the nurse faces the field at all times. Re-establishing the field with new supplies is the only correct response.