Exam 1: Skin assessment/problems and Burns Flashcards
Risk factors for pressure ulcers
Use the Braden Scale
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and shear
Care for pressure ulcers
- Pressure relief devices
- Turning the patient
- Skin care
- Skin cleaning
- Nutrition (fluid, protein and calories
Skin Cancer Assessment: Actinic keratoses
Scaly, commonly called pre-cancerous
Skin Cancer Assessment: Squamous cell carcinomas
Rough, scaly lesion with central ulceration and crusting
Skin Cancer Assessment: Basal cell carcinomas
Small, waxy nodule with superficial blood vessels, well defined borders
Skin Cancer Assessment: Melanomas
New mole or change in existing mole
Skin Cancer Patient Education
Risk factors
- Sun damage
- Lighter skin
- Age
- High altitudes
- Exposure to arsenic
- Severe skin injury
- Immunosuppression therapy
- Chronic skin irritation/scars/burns
Skin Cancer Secondary prevention (ABCDE guide for melanoma)
- Asymmetry
- Border
- Color variation
- Diameter > 6 mm
- Evolving, changing
Superficial Burns
- Epidermis
- Severe erythema
- Blanches
- Red, pink, dry
- No Blister
- Painful but decreases with cooling
- Hyperesthetic (higher sensation)
- Tingling
Examples: Sunburns and Minor steam burns
Superficial Partial Thickness Burns
- Large, thick walled blister
- Cherry red, edema
- Mottled red base
- Broken epidermis
- Wet shiny, weeping
- Blistered
- Painful
- Sensitive to cool and air
Examples: Brief contact with flames, hot liquids, exposure to dilute chemicals
Deep Partial Thickness Burns
- No blisters
- Red , patchy white areas that blanch with pressure
- Moderate edema
- Painful
Examples: Contact with hot liquids or solids, intense radiant energy
Full Thickness Burns
- Pale white, charred
- Deep red, black, brown
- Dry leathery surface
- Severe edema
- Fat exposed
- Tissue disrupted
- No blisters
- Little if any pain
- Incapable of self reepithelialization
- Hematuria (hemolysis of blood)
Deep Full Thickness Burns
- Black
- No edema
- All layers of skin. Extends to muscle, tendons, bones
Burn Types: Thermal
Steam, scalds, fire injuries
Burn Types: Electrical
- Low voltage or high voltage current
- Lightening strike
- fluids to have clear urine. 100 mL an hour output
Burn Types: Chemical
- Alkalis
- Acids
- Do not make vomit
- Fluid Resuscitation
Burn Types: Radiation
- Industrial equipment
- Medical treatment
Inhalation Injury
- SOB, dyspnea
- Hoarseness
- Stridor
- Flaring
- Tachypnea
- Burns to face, neck, mouth
- Sooty sputum
- Singed facial hair
- Swelling of face, neck, trachea
Inhalation injury Treatment
- 100% FiO2 ASAP
- EARLY intubation
- Rest
- Maintain airway
- May need PEEP
Phases of Burn Care characteristics: Resuscitation phase:
- Emergent/Fluid shifts
- Lasts until plasma volume is restored
Phases of burn care characteristics: Acute care phase
- Spontaneous diuresis
- Return capillary integrity
- Mobilization of extracellular fluid
- Wound healing, closure, and prevention of complications
Phases of burn care characteristics: Rehabilitation phase
- Begins at admission
- Long Term
- Mobility and function
- Psychological recovery
Resuscitation Phase Goals:
Hemodynamic stability
- Goal: Keep UOP 0.5-1 ml/kg/hr, SBP> 90
- ECG: Monitor for changes associated with electrolyte imbalance
- Fluid resuscitation
Parkland formula (amount of fluid needed in resuscitation phase)
4 ml LR x %TBSA burned (rule of nines) x weight in kg
- Give half of this amount in 1st 8 hours
- 25% over the next 8 hours
- 25% over the next 8 hours
Example:
70 kg client with 60% burn
4ml x 60 x 70 = 16,800 total
