integumentary/ wound care Flashcards
What are the names of the 3 burn zones?
Zone of Coagulation
Zone of Stasis
Zone of Hyperemia
What is the zone of Zone of Coagulation?
The Zone of Coagulation is the area where irreversible cell death occurs.
What is the Zone of Stasis?
The area that many die without specialized care in 24-48 hours.
What is the Zone of Hyperemia?
The area of minimal cell injury; these cells should recover.
This the percentages of skin coverage as noted by the rule of 9’s.
Head Neck- 9% Anterior Trunk- 18% Posterior Trunk-18% Each Arm- 9% Each Leg - 18% Perineum- 1 %
What is termed a Critical Burn?
3rd Degree - 10%
&
2nd Degree - 30% or more
(complications are common)
What is termed a Moderate Burn?
3rd Degree -
What is termed a Minor Burn?
3rd Degree -
What are common complications with burns?
Infection (leading cause of death is from gangrene)
Shock Pulmonary Complicaitons
Metabolic Complications
Cardiac/ Circulatory Complications
What are the characteristics of a Superficial (1st degree) Burn?
Damage to epidermis only. Pink/ red no blistering (dry surface). Minimal edema. Tenderness/ delayed pain.
What are the characteristics of a Superficial Partial- Thickness Burn?
Epidermis and upper layers of dermis are damaged. Bright pink/ red appearance. Blisters, moist surface, weeping, moderate edema, painful, sensitive to touch, temperature changes.
How long does it take for a Superficial Burn to heal?
Healing is spontaneous within 3-7 days (1 week), no scaring
How long does it take for a Superficial Partial-Thickness Burn to heal?
Healing is spontaneous within 7-21 days (1-3 weeks), minimal scarring/discoloration
How long does it take for a Superficial Full Thickness Burn to heal?
Removal of eschar and skin grafting is necessary for healing to occur. Risk of infection increased. Hypertrophic scarring/ contracture will occur without preventative measures
What are the characteristics of a Superficial Full Thickness (3rd degree) Burn?
Complete destruction of the epidermis, dermis, and subcutaneous tissues, may extend to muscle. Grey, charred or black appearance, poor distal circulation, parchmentlike dry leathery surface. Little pain nerve destroyed
What are the characteristics of a Sub-dermal (4th degree) Burn?
Complete destruction of the epidermis, dermis, and subcutaneous tissue with muscle damage. Charred appearance.Destruction of vascular system may lead to necrosis
How long does it take for a Sub-dermal (4th degree) Burn to heal?
Skin grafting required, scarring will occur. Extensive surgeries needed and amputation may be necessary.
Pressure ulcer stage 1
Non-blanchable erythema of intact skin. May include changes in skin temperature, tissue consistency, or sensation
Pressure ulcer stage 2
Partial-thickness skin loss: involves epidermis and/or dermis.Ulcer is superficial. Presents clinically as an abrasion, blister, or shallow crater.
Pressure ulcer stage 3
Full-thickness skin loss: involves damage to or necrosis of subcutaneous tissue. May extend down to but not through, underlying fascia. Presents clinically as a deep crater.
Pressure ulcer stage 4
Full thickness skin loss: involves extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may be present.
Key points of arterial ulcers.
Pulses poor or absent
intermittent claudication -> pain at rest
thin shiny atrophic skin, loss of hair on the foot and toes,
nails thickend
Key points of Diabetic ulcer.
Usually appear where arterial ulcers appear or where neuropathy appears.
not painful
pulses are present or diminished
Ankle jerk may be negative
Key points of Venus Ulcer
Pulses are normal no pain to aching pain normal temp marked edema stasis dermatitis present
