UWorld: Adult Health: Integumentary

When an abdominal wound evisceration occurs, the nurse should take the following actions: - - *remain calm and stay with pt. & notify HCP* -*place pt. in low fowler's position (no more than 20 degrees)* -assess vital signs -cover the viscera with sterile dressings saturated in NS -document -NPO Toxic epidermal necrolysis - is an acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin). It is a severe form of Stevens-Johnson syndrome *sepsis causes death* Toxic epidermal necrolysis care: - -would care: sterile, most dressings are applied to open areas of the skin -infection prevention: strict sterile technique & *reverse isolation* -fluids and nutrition: *monitor for hypovolemia* -Hypothermia prevention *keep too 85F or more*