Complex Exam 4 - tissue integrity Flashcards
When does the emergent/resuscitative phase begin and end?
- begins with injury
- lasts 24-48 hours
What are the priorities during the emergent/resuscitative phase?
- airway
- circulation
- perfusion (fluid replacement)
- pain
- infection (wound care)
- body temperature
- emotional support
When does the acute phase begin and end?
- begins at 36-48 hours
- ends with closure of the wound
What are the priorities during the acute phase?
- cardio
- respiratory
- GI
- infection (wound care)
- pain
- psychosocial
When does the rehabilitative phase begin and end?
- begins when most of the burn area has healed
- ends when the client achieves the highest level of functioning possible (can take years)
What are the priorities for the rehabilitative phase?
- psychosocial
- scars, contractures
- resumption of activities
What can cause dry heat injuries?
- open flames
- explosions
What can cause moist heat injuries?
hot liquid or steam
When are scalding injuries more common?
- older adults
- young children
What can cause contact burns?
hot metal/tar/grease
What can cause chemical burns?
caustic agents
- cleaning: drain/oven cleaner, bleach
- industrial: soda sulfuric acid
What can electrical burns cause?
- loss of organ function
- tissue destruction
- possible amputation
- cardiac/respiratory arrest
What can cause thermal burns?
ignition of clothes from heat/flames produced by electrical sparks
What causes flash (arc) burns?
electrical currents traveling through the air
What causes conductive electrical injuries?
touching electrical wiring/equipment
What causes radiation burns?
- cancer treatment
- sunburn
What should be removed from the body after a burn occurs?
clothing/jewelry that might conduct heat
What can be used on burns to help with the pain? What should not be used?
- YES: cool water soak, cool water
- NO: ice
How can contamination and hypothermia be prevented?
covering the burn wit a clean cloth
How should burns be cleaned?
with mild soap and tepid water (no friction)
What type of ointment should be used?
antimicrobial
What type of dressing should be used to cover the burn if clothing is irritating?
non-adherent hydrocolloid dressing
What immunization might be needed after being burned?
tetanus
What happens during the initial/resuscitation phase?
- increased HR, BP, BG
- decreased GI motility
What cardio should be monitored with moderate/major burns?
- edema
- pulses
- cap refill
- pulse ox/O2 sat
- BP
- EKG
What respiratory should be monitored with moderate/major burns?
- RR, depth
- upper airway edema
- crowing, stridor, dyspnea
- trach
- chest tube
When might upper airway edema occur?
8-12 hours after starting fluid resuscitation
When would intubation be needed?
crowing, stridor, and dyspnea
When would ventilation be needed?
inhalation injury
What should be done every hour?
- incentive spirometer
- suctioning
What should be done for airway injury?
- supplemental O2
- coughing
- deep breathing
- elevate HOB
What should be done for F&E imbalances (hypovolemic shock)?
- daily weight
- I&O’s
- labs
- IV replacement
What should be assessed when monitoring for a wound infection?
- discoloration
- edema
- odor
- drainage
- fluctuating temp and HR
What should be done for a suspected wound infection?
- culture
- antibiotics
- labs
What is needed for dressing changes?
surgical asepsis
What can scar tissue cause?
limited movement, contractures
What should be done at least 3 times/day for mobility?
active or passive ROM
What position is encouraged?
neutral with limited flexion
What should be encouraged for mobility?
- splints
- ambulation
- compression dressings for up to 24 months
What is done if there is a loss of circulation?
fasciotomy
What can rhabdomyolysis lead to?
kidney failure
What does compartment syndrome put the patient at risk for?
infection
How many calories should someone consume after burns?
5000/day
What happens to caloric needs 4-12 days after the burn?
they double or triple
Why should protein be increased?
- prevents tissue breakdown
- promotes healing
Why should calories be increased?
- increased metabolic demands
- prevents hypoglycemia
Why would enteral therapy or TPN be needed?
- decreased GI motility
- increased caloric needs
What does a superficial thickness (1st degree) burn involve?
epidermis
What does a superficial thickness (1st degree) burn look like?
- pink to red
- NO blisters
- mild edema
- NO eschar
What burn is painful/tender and sensitive to heat?
superficial thickness (1st degree)
How long does it take for superficial thickness (1st degree) burns to heal?
3-6 days
Do superficial thickness (1st degree) burns have scarring?
NO
What is an example of a superficial thickness (1st degree) burn?
sunburn
What does a superficial partial thickness (2nd degree) burn involve?
the entire epidermis and some parts of the dermis
What does a superficial partial thickness (2nd degree) burn look like?
- pink to red
- blisters
- mild to moderate edema
- no eschar
How long does a superficial partial thickness (2nd degree) burn take to heal?
3 weeks
Does a superficial partial thickness (2nd degree) burn have scarring?
NO
What is an example of a superficial partial thickness (2nd degree) burn?
brief contact with a hot object
What does a deep partial thickness (2nd degree) burn involve?
the entire epidermis and deep into the dermis
What does a deep partial thickness (2nd degree) burn look like?
- red to white
- NO blisters
- moderate edema
- eschar soft and dry
What type of burn is painful and sensitive to touch?
deep partial thickness (2nd degree) burn
How long does it take a deep partial thickness (2nd degree) burn to heal?
2-6 weeks
Does scarring and grafting occur with a deep partial thickness (2nd degree) burn?
yes
What is an example of a deep partial thickness (2nd degree) burn?
- flames and scalds
- grease/tar/chemical burns
What does a full thickness (3nd degree) burn involve?
- the entire epidermis
- can extend into the SQ tissue
- nerve damage
What does a full thickness (3nd degree) burn look like?
- red, black, brown, yellow, or white
- NO blisters
- severe edema
- eschar hard and inelastic
Does a full thickness (3nd degree) burn have sensation?
it is minimal or absent
How long does it take a full thickness (3rd degree) burn to heal?
weeks to months
Do scarring and grafting occur with a full thickness (3nd degree) burn?
yes
What are examples of a full thickness (3nd degree) burn?
- scalds
- grease, tar, chemical, electrical burns
What does a deep full thickness (4th degree) burn involve?
- all layers of the skin
- muscles/tendons/bones
What does a deep full thickness (4nd degree) burn look like?
- black
- NO blisters
- NO edema
- eschar hard and inelastic
How long does it take a deep full thickness (4nd degree) burn to heal?
weeks to months
Do scarring and grafting occur with a deep full thickness (4nd degree) burn?
yes
What is an example of a deep full thickness (4nd degree) burn?
- electrical burns
- flames
What happens to facial hair (nose, eyebrows, eyelashes) with inhalation damage?
singed
What happens to the sputum with inhalation damage?
sooty
What type of cough signifies impending loss of airway?
brassy
Where is edema present with carbon monoxide inhalation?
upper airway
Where is sloughing present with carbon monoxide inhalation?
respiratory tract mucosa
What percent is the head with the RON?
4.5% on each side
What percent is the chest with the RON?
18% on each side
What percent is each arm with the RON?
4.5% on each side
What percent is each leg with the RON?
9% on each side
What percent is the pelvic area with the RON?
1%
How is the amount of fluid needed after a burn calculated?
Parkland formula
4 mL x weight (kg) x TBSA % = total mL in 24 hours
How should fluid resuscitation be administered?
- the first half over 8 hrs
- the second half over the next 16 hours
