Integumentary System Part 1 Flashcards
The Skin
Largest organ in the body
3 Layers: Epidermis, dermis, and hypodermis (subcutaneous/fatty tissue)
Provides us with protection from the environment, mechanical and chemical assaults
Provides immunity and protection against infection
***Helps to regulate our body temperature
Infection is the most important complication: HANDWASHING!
Fluid loss/Electrolyte Imbalances are also major
Skin Layers (Epithelial)
Epidermis is the outermost layer of the skin and it contains epithelial cells which reproduce and regenerate every 28 days (epithelialization)
Skin Appendages (hair, nails, and glands) arise from the epithelial level and receive their nutrients, electrolytes, and fluids from the dermis. 2 Major types of glands:
Sebaceous (secretes sebum around hair follicles to prevent dryness and bacteriostatic action)
Sweat glands (apocrine located in the axillae, breast areola, umbilical, and anogenital areas secrete milky substance that become odoriferous with bacteria and the eccrine sweat gland secretes watery solution composed of salts, ammonia, urea.
Burns Types: Thermal
Thermal burns caused by exposure to flame or a hot object produce micro vascular and inflammatory responses within minutes of the injury.
Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space.
In large burns, this fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state (burn shock).
Burns Types: Chemical
Chemical burns are the result of exposure to acid (many household cleaners), alkali (oven and drain cleaners, fertilizers), or organic substances (phenols such as chemical disinfectants or petroleum products such as gasoline).
The extent of injury depends on the concentration of the substance, the amount, the duration of exposure, and the mechanism of chemical action.
Immediately remove the burning agent and profusely irrigate the skin and eyes if involved.
Chemical Burns cont.d
Acid substance results in a coagulation necrosis with an eschar covering that prevents continued tissue damage beneath the layer of eschar.
Alkali substance cause more damage then acid since it causes protein hydrolysis & liquefaction producing a soupy wound, which allows continued tissue damage into deeper structures until the pH is WNL.
Organic substances may be absorbed systemically producing renal and hepatic toxicity. Inhalation can cause direct lung injury with pulmonary and cardiovascular effects.
Tissue injury may continue for up to 72 hours after a chemical injury
Burns Types: Electrical
Electrical burns result from the conversion of electrical energy into heat.
The extent of thermal injury depends on the type of current, the pathway of current flow, local tissue resistance, and the duration of contact.
Tissue resistance depends on its thickness and amount of moisture (fat and bone offer the most resistance, nerves and blood vessels the least).
“Iceberg effect”- most of the damage is below the skin and the extent (vital organs effected) is difficult to determine.
Things to consider for Electrical burns
Risk of dysrhythmias up to 24 hours after injury (monitor).
Risk of ATN due to released myoglobin pigments (from the injured muscle tissue and damaged RBCs).
Risk of Cervical spine injury (power line fall?) - use collar and leave on until intact spine has x-ray verification
Burns Types: Radiation
Radiation burns result from radiant energy being transferred to the body resulting in production of cellular toxins. Usually the result from radiation therapy or from a lab incident.
The greater the exposure, the more significant the damage. Effect mostly evident on cells that reproduce rapidly (skin, blood vessels, intestinal lining and bone marrow)
Burns: Associated Areas
Inhalation injuries occurs with inhalation of hot air or noxious chemicals that damage respiratory tract tissues.
Vocal cords and glottis protect lower airways.
3 Types of smoke inhalation injuries:
1) Carbon Monoxide poisoning displaces O2 on the hemoglobin molecule causing hypoxia and carboxyhemoglobinemia and death (skin color is cherry red). Treat with 100% humidified O2. GET ABG TO ASSES PAO2
2) Above glottis (thermal - hot air, steam, smoke) produces edema and eventual obstruction (medical emergency). S/S includes facial burns, singed nasal hairs, hoarseness, stridor, dyspnea, dark sputum.
3) Below the glottis (chemical) injury to lower resp. tract related to duration of exposure can result in pulmonary edema (ARDS) 12-24 hours after insult.
Inhalation Injuries: Symptoms
Singed Nasal Hairs, Blackened Mucosa
Restlessness/ Confusion
Hoarseness, Stridor, Dyspnea, Wheezing
Carbonaceous sputum
Crackles in first few hours-poor prognosis
Inhalation Injury: upper & lower airway
Physiology Increased capillary permeability Sub-alveolar edema Bronchioles susceptible Surfactant loss
Mortality
Without thermal injury 5-8%
With major thermal injury and ARDS >50%
Treatment Oxygen Intubation if needed Pulmonary Toilet: turning, coughing, deep breathing, etc ABG/CXR Monitoring
Inhalation Injuries RED FLAGS
Confined area incident Singed nasal hairs Oral or pharyngeal mm burns Perioral area or neck burns Carbonaceous sputum Voice changes
Burn Classifications
According to the American Burn Association (ABA) severity determined by depth of burn, extent of burn calculated in % of total body surface area (TBSA), location of burn, and patient risk factors.
Burns: 1st degree
Superficial involves the avascular epidermis and appears red from blood vessel dilatation.
Area is erythema, blanches, painful, minimal edema, no blisters, dry skin (i.e. sunburn or a brief scald from a hot liquid)
Heals in 3 to 6 days, some sloughing of the epidermal layer
No scarring
Cold compress/Ice/Tylenol/Aloe with Lidocaine
Partial Thickness
Partial thickness involves the epidermis and part of or all the dermis.
Superficial partial thickness (second degree) involves the epidermis and the papillary layer of the dermis. Caused by hot liquids, hot objects or flash flame.
Erythema, no immediate blisters (appear later), +blanching, mild edema, painful.
Heals in 10 to 14 days via re-epithelialization, no scarring but potential for hypo/hyperpigmentation.
NO ice, but cool water/antibiotic soap. Silvadene is a popular anti-bacterial. Elevate extremity to reduce edema.
Superficial Partial Thickness Skin Destruction (2nd degree)
Fluid-filled vesicles that are red, shiny (may be wet if the vesicles have ruptured).
Severe pain caused by nerve damage
Mild to moderate edema.
Deep Partial Thickness
Deep Partial Thickness (second degree) involves the epidermis and the reticular layer of the dermis (deep layer).
May be caused by flame, hot liquids, radiation, tar, or hot objects
Cherry red or pale, sluggish or absent capillary refill, moist fluid vesicles (red, shiny and wet), moderate edema, and very painful to touch and air due to nerve injury.
Heals in 3-4weeks and potential for scarring and hypo/hyperpigmentation.
May require skin grafting for optimal function or appearance.
Full thickness burns
Full thickness (third and fourth degree) involves epidermis, dermis, and subcutaneous layer and possibly muscles, tendons, and bones.
May be caused by flame, electricity, or chemicals
Dry, waxy white, red, or black charred like appearance, leathery (inelasticity, insensitive to pain due to destruction of nerves, absent capillary refill due to visible thrombosed vessels).
Requires skin grafting, possible flaps or amputation.
Visible scarring
Extent of a Burn
Rule of nines- easy to remember for initial assessment of an adult
Head & neck=9%,arms=9% (4.5% anterior/4.5% posterior), ant. trunk= 18%, post. trunk=18%, legs= 18% each, perineum= 1%
Palmer method (One palm surface =1%) Burn extent is often revised after edema subsides and demarcation of injury zones occurs.
Major Burn
Adults 25% TBSA or greater
Children 10-15% TBSA or greater
Physiologic response to a major burn is systemic not localized like in a small burn
MAJOR burns require:
fluid resuscitation & transfer to burn center
Burn Management
Face, neck, and circumferential burns to the chest/back area may inhibit respiratory function with mechanical obstruction secondary to edema or leathery, devitalized tissue (eschar) formation. These injuries may cause inhalation injury and respiratory mucosal damage.
Hands, feet, and eye burns may make self-care difficult and jeopardize future function. Buttocks or genitalia burns are susceptible to infection. Circumferential burns to extremities can cause circulatory compromise distal to the burn (check pulses).
Burn management is organized chronologically into three phases: emergent (resuscitative), acute (wound healing), and rehabilitation (restorative). Overlaps in care exist from one phase to another.
Pre Hospital Management
Stop burning- remove patient from source without endangering the rescuers and lavage site with water (no ice, danger of frostbite)
ABC’s (check for singed nasal hairs, soot, carbon sputum, dark mucus membranes), monitor RR and depth, monitor pulses (elevate burned limb above heart due to edema formation) and cardiac rhythm.
Analgesia for pain
<10% TBSA
Flush with water
Cover wound with clean, cool, tap water-dampened towel
Provide warmth- wrap in dry, clean sheet
Burn Referral Criteria
Partial thickness and full thickness burns>10% if <10yrs or >50 yrs of age and more then 20% for all other ages.
Full thickness burns
Burns of face, hands, eyes, ears, feet or perineum
All inhalation injuries, electrical and chemical burns
Circumferential burns of extremities and/or chest
All burns complicated by fractures and trauma
All burns in poor risk children/children< 2yrs. Old
All burns with preexisting medical conditions
Emergent Phase
Emergent Phase=time of injury to time of diuresis
Usually last 24-48 hours but can last 3 days
Onset of hypovolemic shock and edema due to increased capillary permeability.
Leakage of water, sodium and albumin into the interstitium resulting in a decreased blood volume and an ↑hematocrit and ↑viscosity of the blood. (↓Na, ↑K)
If fluid replacement with crystalloids is adequate, the capillary membrane permeability is restored. The interstitial fluid gradually returns to the vascular space.
Inflammatory response & healing: ↑neutrophils & monocytes. Fibroblasts & collagen begin wound healing w/in 6-12 hours
Emergent Phase cont.d
Immune system impairment- 1st line of defense destroyed; bone marrow suppression;↓function of WBCs
Shivering occurs as a result of chilling (insensible loss with evaporation) or anxiety/pain.
Most patients are alert. Unconsciousness or altered mental status is usually a result of hypoxia associated with smoke inhalation, head trauma, or excessive sedation or pain medication.
Ileus : Lack of perfusion to the GI tract.
End of emergent phase:
Fluid mobilization, diuresis begins ( low urine specific gravity)
Emergent Phase Treatment
Emergent Phase – Airway management Early intubation (esp. face & neck burns) Edema usually resolves w/in 3-6 days 100% humidified O2 Escharotomies of chest wall Fiberoptic bronchoscopy
Fluid Therapy: Emergent Phase
Establish two large-bore IV lines
For >30% TBSA burn: central line and an arterial line
Goal: UO >30-50 ml/hr (or 0.5-1.0 ml/kg/hr),SBP>90 ,& HR<120
Fluids: Lactated Ringers (may need NaHCO3 added to alleviate any metabolic acidosis)
Parkland formula (mostly used)
4mL x kg x %TBSA
½ first 8 hours
¼ each 2nd and 3rd 8 hrs
Emergent Phase-Wound Care
Wound care commences after ABCs /fluids established.
Cleanse with surgical detergent/disinfectant
Shower is better than tub immersion (electrolyte loss after 20-30 minutes/ cross-contamination). Warm room
Debridement to remove necrotic tissue and fasciotomies to alleviate compartment syndrome
Avoid infection- antimicrobial dressings, sterile technique, avoid cross contamination, hand wash
Wounds>50% use temp.grafts. Topical antibiotics.
Emergent Phase -Pain management
IV Morphine is the drug of choice
Dilaudid, Percocet, NSAIDs effective
Control anxiety with a sedative (Ativan, Haldol)
Control GI discomfort (stress!) H2 blockers and proton pump inhibitors. Monitor for paralytic ileus
Emergent Phase - Nursing Care
ABCs, VS, cardiac arrhythmias, pain management, I&O, monitor pulses and sensations (compartment syndrome),monitor labs (CBC, electrolytes esp. Na and K+, urine SG, ABGs, myoglobinuria, hemoglobinuria, carboxyhemoglobin), positioning (elevate extremities and no pillow with ear and neck burns), sterile wound care, & monitor for infections. Psychological support for patient, family and friends.
