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Clinical Conditions > Burns > Flashcards

Burns Flashcards

1
Q

Skin

A
  • largest organ in the body
    Functions of the skin:
  • protection against infection (which is why when there is burns, there’s easily infections)
  • prevention of loss of body fluids
  • control of body temperature
  • functioning as an excretory organ
  • cushioning the deeper structures from mechanical injury
  • production of vitamin D
  • helping to determine personal identity
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2
Q

Layers of skin

A
  • epidermis
  • dermis
  • subcutaneous tissue
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3
Q

Epidermis

A
  • thin no vascular outer layer
  • consists of layers of epithelial cells
  • barrier to bacteria and moisture loss
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4
Q

Dermis

A
  • bulk of the skin
  • hair follicles, blood vessels, sweat glands, nerve endings, and sebaceous glands
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5
Q

Subcutaneous tissue

A
  • deepest layer
  • mostly fat that provides insulation and cushioning
  • contains larger blood vessels and nerves
  • anchors the skin to the bones and muscles
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6
Q

Pathophysiology of burns

A
  • zone of hyperemia
  • zone of stasis
  • zone of coagulation
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7
Q

Zone of hyperemia

A
  • tissue is damaged but with proper care, can heal and recover
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8
Q

Zone of stasis

A
  • damage results in decreased tissue perfusion
  • tissue in this zone may be salvageable
  • try to increase perfusion to this area and prevent any irreversible damage
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9
Q

Zone of coagulation

A
  • area exposed to the most heat and endures the most damage
  • area of irreversible tissue destruction
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10
Q

Causes of burn injuries

A
  • fire (most common)
  • scald (injured with hot liquid or steam)
  • hot object
  • electrical
  • chemical
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11
Q

Diagram (slide 6)

A
  • 1 person per 10,000 people in the U.S. requiring inpatient hospitalization at a burn center
  • more common in males (risk-taker personality)
  • median age = 40 years
  • 45% of all burn injuries were caused by flame or flash
  • scalds make up 58% of pediatric cases
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12
Q

Depth of burn

A
  • how deep into the skin layers the burn extends and its duration
  • superficial (first degree burn)
  • partial thickness (second degree burn)
  • full thickness (third degree burn)
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13
Q

Superficial burn injury (first degree)

A
  • involves only the epidermal layer of skin
  • characterized by redness and pain
  • wound is dry
  • no blisters
  • would blanch easily (blanch is when you touch/press your skin and it turns to white, then turns back to normal color again)
  • sensitive to air and/or light touch
  • sunburn or flash from an explosion
  • heal spontaneously within 7 days
  • leave no permanent scar
  • doesn’t extend to 2nd layer of skin (dermis)
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14
Q

Partial-thickness burn (second-degree)

A
  • destroys the epidermal layer
  • extends down into the dermal layer of the skin
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15
Q

Superficial partial thickness burn (second degree)

A
  • damage in the upper layers of the papillary dermis (burned half way through the dermis)
  • like a sunburn that peels
  • clear blisters and weeping, wet skin
  • burn will blanch
  • heal in 3 weeks
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16
Q

Deep partial thickness

A
  • affect the entire epidermis and dermis (burned all the way through)
  • spare the base of the hair follicle
  • may have blisters with bloody fluid
  • does not blanch
  • painful because exposed nerve endings
  • may require grafting
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17
Q

Full-thickness burn (third degree)

A
  • destroys the entire epidermal and dermal layers of skin
  • extends into the subcutaneous tissue
  • charred black, cherry red, tan, or pearly white in color
  • dry, leathery, and hard in texture
  • nerve endings are destroyed
  • can remain sensitive to deep pressure
  • residual scar
  • severe risk for contractures formation (when have 3rd or 4th degree burns, you get tight skins from the scars which leads to contractures when you’re not having a full ROM
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18
Q

Deep full-thickness burn (fourth degree)

A
  • destroys all skin layers
  • extends into the muscle tendon or bone (bone, skin, muscle, tendons are gone)
  • charred or mummified appearance
  • challenging to close
  • can result in partial or total loss of function
  • severe damage to underlying structures
  • may lead to amputations
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19
Q

Inhalation injury

A
  • if you get burns in the upper torso, chest, shoulders, face, it is likely that you will also get inhalation injury because you were breathing in that hot air and burning too
  • setting of a thermal injury in an enclosed space
  • reduce oxygen saturation
  • cyanosis = a bluish-purple color of the skin
  • stridor = an abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway
  • visible mucosal change in the upper airway
  • presence of facial burns
  • singed nasal hair
  • hoarse voice
  • wheezing
  • hypoxia = low levels of oxygen in your body tissues
  • cough
  • once your pulse is less than 90%, the oxygen is not traveling well in your blood and is not getting to your heart, brain, liver, and other organs
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20
Q

How to diagnose the type of burn injuries

A
  • look at the depth of the burn
  • determine the TBSA (total body surface area) involved
  • rule of nines = a way to do the total body of surface area
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21
Q

Burn shock

A
  • burns in excess of 15-20% totally body surface area (TBSA)
  • occurs with the first 24 hours
  • peaks around 6-8 hours after injury (the worst part)
  • burns cause the capillaries to become more permeable, allowing plasma to leak into the surrounding tissues, resulting in edema
  • this loss of circulating fluid reduces blood volume
  • increase in blood viscosity
  • low cardiac output
  • to treat it is through an IV fluid
  • burn shock = full loss of fluids (not necessarily blood)
  • can lead to multiple stem organ failure
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22
Q

Hypermetabolism

A
  • goes into the overload of trying to heal the burn
  • resting metabolism = 1200 calories and because of hypermetabolism, it starts to break down muscles to get the fuel and energy (can be in a coma)
  • prolonged stress response in the body
  • release of catecholamines, cytokines, and insulin
  • initiates and mediates a hypermetabolic response and increased energy expenditure and protein turnover in the body
  • increased basal metabolic rate of up to 40% above normal values
  • result in severe muscle loss, prolonged ventilation days, impaired immune responses, and eventually death
  • energy expenditure is most significant in the first weeks postburn
  • protein heals wounds (heals muscles)
23
Q

Infection

A
  • quick dressing changes and sterile changes are so important
  • the skin barrier is injured
  • high risk for infection
  • at risk for sepsis
  • caused by the body’s response to an infection in which chemicals are released into the blood stream to fight an infection but cause inflammation throughout the body instead
  • leading cause of mortality in adult and pediatric burn patients
24
Q

Scars

A
  • the darker the skin pigmentation, the more likely you will get hypertrophic or keloid scars
  • fibrous tissue that replaces normal tissue after injury
  • typical scars are initially red in color and fade as the fibrous tissue begins to develop
  • as wound closes, burn scars begin to form

2 types:
- hypertrophic scars
- keloid scars

25
Q

Hypertrophic scars

A
  • uncontrolled production of fibroblasts and excess deposit of collagen tissue
  • raised, red, and rigid
  • remain within the boundary of the original wound
  • will eventually fade in color and become more pliable
  • African Ethnic origin
  • areas in the body with more stretch or motion such as shoulder and trunk have prolonged healing
26
Q

Keloid scars

A
  • excessive fibrosis, nodular (lump) proliferations that project beyond the margins of the original injury
  • tender and painful
  • can be difficult to treat
  • physical, cosmetic, psychological, and social concerns
  • African Ethnic Origin
  • does not regress over time
  • same for keloid scars that the darker the skin pigmentation, the more likely they are prone to keloid scarring as well
27
Q

Contractures

A
  • wound healing
  • shortening and tightening of burn scar
  • permanent shortening of the muscle, tendon, and scar tissue
  • can produce deforming or distortion
  • shoulder, elbow, and wrist are the most common joints
  • long-term consideration when working with burns is making sure the scar tissues stay loose and pliable so that it does not affect the joints and that it allows for the stretching of the skin
28
Q

Course and prognosis of burns

A
  • depends on the depth and surface area of the burn
  • superficial burn will heal 3-4 days = epidermis sloughs (dead tissue separating from living tissue)
  • superficial partial-thickness burn will heal within 3 weeks = no scarring and pigmentation changes
  • deep partial-thickness burn will heal in 3 weeks or longer = results in significant scarring and contractures
  • full-thickness burn injury will not heal spontaneously = both layers of the skin are destroyed, its healing time is dependent upon the availability of graft donor sites, and can potentially affect all the body systems
29
Q

Complications

A
  • infections = pneumonia, UTI, and wound infection
  • organ failure = renal, respiratory, and multiple organ failure
  • 60% of deaths from burn injuries are attributed to multi system organ failure
  • inhalation injuries
30
Q

Treatments for burn injuries

A
  • skin grafts
  • medical management
  • inhalation injuries
  • fluid resuscitation
  • nutritional support
  • debridement
  • pain management
  • burn dressings
  • excision
  • grafting
31
Q

Medical management

A
  • considered severe trauma
  • specialized care
  • transferred to burn center if meet the criteria
32
Q

Inhalation injuries (what to do if have that)

A
  • maintain adequate oxygenation
  • supplemental oxygen to keep O2 saturation above 90%
  • respiratory therapy
  • early ambulating (moving around prevents pneumonia and bed sores)
  • airway suctioning
  • intubation and ventilator support if severe
  • management of carbon monoxide or cyanide toxicity
33
Q

Fluid resuscitation

A
  • administration of IV fluids
  • crystalloid (lactated Ringer solution) = solution that contains sodium, calcium, potassium, and lactate (you need lactic acid when you work out and when you’re sore, it means that the lactic acid left the muscles; lactate is one of the chemicals in the muscles that helps with muscle contraction)
  • its goal = maintain intravascular volume sufficient enough to ensure perfusion and oxygen to all tissues and organs
  • formulas used to calculate fluid needs based on the burn size and patient weight
  • too much fluid can lead to compartment syndrome = internal edema within a part of the body, often an extremity that can decrease circulation to the structure and thus putting them at risk for fluid overloading
  • urine output is monitored
34
Q

Nutritional support

A
  • needed to meet the increase basal energy expenditure (hypermetabolism)
  • most patients cannot consume enough calories through eating = thus does NG (nasogastric) feeding to get enough nutrition
  • high calories and high protein = helps with debridement
35
Q

Debridement

A
  • cleansing and removal of non-adherent and non-viable tissue = eschar which is the dead tissue that sheds from the health tissue facilitates bacterial access and acts as the common denominator for burn sepsis
  • daily cleansing and debridement = necessary to decrease the potential for burn wound sepsis, to facilitate healing, and to prepare the wound for grafting
  • painful procedure and it is important to make sure that the patient has been medicated with analgesics and/or sedative medication prior to starting the dressing change
36
Q

Pain management

A
  • pain meds = morphine, fentanyl, or codeine
  • sedation = ketamine
  • anxiety = diazepam or midazolam
  • anticipatory anxiety before dressings
  • virtual reality, massage therapy, sensory focusing, guided imagery, relaxation techniques, and music therapy
37
Q

Burn dressings

A
  • cleansed wound, non-adhesive, absorbent, and antimicrobial dressing should be applied
  • barrier to the environment to prevent infection
  • assist in the management of wound fluids
  • range from two times a day to weekly
  • dependent on the dressing material and amount of seepage
  • if outer bandages become saturated with drainage, replace them with dry outer bandages and prevent the wicking (absorbing) of bacteria down to the surface of the wound
38
Q

Types of burn dressings

A
  • topical dressings
  • silver-containing compounds
  • silvadene
39
Q

Topical dressings

A
  • provide protection
  • all gas exchange and moisture retention
  • provide comfort
40
Q

Silver-containing compounds

A
  • antimicrobial properties
  • reduce wound pain
  • can cause silver toxicity, resistance, and skin discoloration
41
Q

Silvadene

A
  • effective against bacteria and some antifungal activity
  • a cream that helps keep the moisture in
42
Q

Excision and grafting

A
  • excision is completed when the patient is stabilized and within 48-72 hours of the injury to reduce blood loss and morality rates
  • timely closure of wounds can prevent dehydration and assist in reducing the risk of infection
  • grafting priorities are influenced by the location and the size of the burn = hands have priorities because of its function and face and back because of cosmetic concerns
  • scraps away the wound to accept the graft (need blood because it’s active, alive tissue that will allow the cut out skin to attach to the surface)
43
Q

Skin graft

A
  • a surgical procedure where we take a piece of healthy skin and attach it to an area of burned skin that has been excised (cleaned)
  • patient donor sites (autograft)
  • surgical transplantation of patient’s own skin
  • donor site takes about 7-10 days to heal (can sometimes be more painful than the actual burn site because the donor site as full of nerves and arteries and can feel everything
  • mesh grafts = allow for more area to be covered than the actual size of the donor site (takes the skin and puts it through a machine that puts holes in it to stretch it out for more surface area)
  • sheet graft = donor skin is laid intact over the area, is more durable and less scarring, but has limited availability
  • graft is fragile and susceptible to loss
  • shearing/motion, friction, and infection cause graft loss
  • grafted area is often immobilized in a functional position (typically 4-6 days)
44
Q

When have limited availability of donor sites (grafting)

A
  • allograft = donor skin taken from another living or deceased person (the body will reject allograft 7-12 days after placement, it is just to buy some time to heal)
  • xenograft = graphs from unrelated species like pig skins, not as affective as allografts
  • skin substitutes = alloderm or biobrane

*the area that has the graft is immobilized to allow the graft to really stick to the body

45
Q

Scar management

A
  • compression therapy
  • moisturization
  • stretching and range of motion exercises
46
Q

Compression therapy

A
  • purpose = helps reduce hypertrophic scarring by applying constant pressure
  • method = use of custom-fitted pressure garments or elastic bandages to compress the scar tissue (garments are typically worn 23 hours a day for several months to a year)
47
Q

Moisturization

A
  • purpose = keeps the skin hydrated, reducing dryness and itching
  • method = regular application of non-fragranced, hypoallergenic lotions or creams to the affected skin area
48
Q

Stretching and range of motion exercises

A
  • purpose = prevents tightness and maintains flexibility around the scar
  • method = gentle stretching exercises prescribed by a physical or occupational therapist to maintain mobility in affect areas
49
Q

Occupational implications

A
  • ADLs
  • health management
  • rest and sleep
  • education and work
  • play, leisure, and social participation
  • influenced by size, location, and depth
  • deep partial thickness or full thickness burns have more potential to impact occupational performance
  • severe scar formation
  • contractures
  • joint restrictions
50
Q

Occupational implications of ADLs

A
  • decreased joint mobility and joint function
  • decreased passive and active ROM
  • edema
  • scarring
  • contractures
  • long periods of immobilizations
  • decreased muscle power
  • decreased muscle endurance
51
Q

Occupational implications of health management

A
  • physical limitations may impair their ability to participate independently in health and wellness routines
  • exercise programs (consisting of ROM, strengthening, and cardiovascular exercises) implemented early in the course of recovery and continued until premorbid status is achieved which is recommended for burn survivors (intense process)
  • early mobilization, ambulating, active ROM, and limited bed rest have also been found to improve the burn survivors’ outcomes (bed rest is not good, whenever medically possible, don’t do bed rest)
52
Q

Occupational implications of rest and sleep

A
  • sleep and rest disturbance cause more stress
53
Q

Occupational implications of education and work

A
  • critical to return to school as soon as their health allows to assist with their recovery and reintegration back into their normal routines and roles
  • work following a burn injury is critical because it allows the burn survivor to resume an important identity and a valued role within their life
54
Q

Occupational implications of play, leisure, and social participation

A
  • important to consider the impact on mental functions that a burn injury may have when planning a return to play, leisure, and social participation
  • traumatic and catastrophic nature of a burn injury, burn survivors may suffer symptoms of PTSD, depression, and body image and self-image dysmorphia (a mental illness involving obsessive focus on a perceived flaw in appearance)
  • the specific mental functions of “emotional” and “experience of self and time” are often overshadowed in persons who sustain burn injuries as medical personnel are focusing on survival
  • support and interventions focused on loss, grief, acceptance of body image and self-image, PTSD, anxiety, and depression should be provided
  • recognize and assist patients, families, and friends in dealing with the psychological and psychosocial impact of a major burn injury

Clinical Conditions (7 decks)

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