Patho Exam 2 Flashcards
1
Q
Sickle cell anemia is a(n) ____ [genetic inheritence] disorder where there is an abnormality in ___. People of what descent are most likely to have it?
A
Sickle cell = AUTOSOMAL RECESSIVE, Abnormality in HEMOGLOBIN. Common in patients decendent from Sub-Saharan Africa, India, Saudia Arabia, Mediterranean countries.
2
Q
In sickle cell anemia, the RBC changes shape from __ to __ after they are ___. This leads to ___.
A
Sickle cell = RBC changes from BICONCAVE DISC to SICKLE CELL after it is DEOXYGENATED. Leads to VASO-OCCLUSION
3
Q
What physiologic stressors can cause a sickle cell crisis/episode?
A
- Viral/bacterial infection
- Hypoxia
- Dehydration
- Extreme temperatures
- EtOH
- Fatigue
4
Q
What are symptoms of a sickle cell episode/crisis?
A
- Pain
- Bone & Joint involvement
- Vascular complications
- Pulmonary issues
- Neurologic issues
- Renal and spleen complications –> pain
5
Q
A pt with sickle cell anemia would likely present with high or low values of the following: Hgb, Hct, WBC
A
Hgb - LOW
Hct - LOW
WBC - HIGH
6
Q
In polycythemia vera, we see [increased/decreased] RBC.
In primary Polycythemia vera, the RBC change is due to an abnormality in __. In secondary, it is caused by natural or artificial increases in the production of __ that results in increased production of ___ generally caused by ___.
A
In polycythemia vera, we see INCREASED RBC.
In primary Polycythemia vera, the RBC change is due to an abnormality in BONE MARROW. In secondary, it is caused by natural or artificial increases in the production of ERYTHROPOEITIN that results in increased production of ERYTHROCYTES generally caused by PROLONGED HYPOXIA SECONDARY TO ALTITUDE OR OBSTRUCTIVE LUNG DISORDERS. Renal disorders are also associated with inappropriate erythropoeitin production
7
Q
General signs and symptoms of RBC disorders include…
A
Low RBC
- Fatigue
- SOB
- Decreased distal sensation
High RBC
- Increased hematocrit
- Headache or dizziness
- Clubbing of fingers
- Weight loss
- High blood pressure
- Easy bruising
- Peripheral neuropathies due to blocking of distal capillaries
- Gout (sometimes a complication)
8
Q
What are clinical manifestations of leukemia?
A
Anemia Infection Bleeding Fever Weight loss Fatigue Bone marrow suppression Lymph node and spleen enlargement
9
Q
In leukemia, we might see low (aka ___) or high (aka ___) WBC. Describe the patient risks with each
A
Low WBC = Leukopenia
- Increased risk of catching an infection with low WBC count (neutropenia)
- Increased precautions that are facility dependent
High WBC = Leukocytosis
- Dehydration
- Tachycardia
- Mental Status changes
10
Q
___ is a decreased number of platelets in the blood. ___ is an increased number of platelets in blood.
A
Decreased # platelets = Thrombocytopenia
Increased # platelets = Thrombocytosis or Thrombocythemia
11
Q
What causes platelet dysfunction?
A
Congenital or caused by drugs
12
Q
___ is a plasma clotting protein abnormality resulting from a deficiency in Factor __ or __.
A
HEMOPHILIA is a plasma clotting protein abnormality. Deficiency of Factor VIII or IX
13
Q
Adverse clinical presentations associated with hemophilia include…
A
- Hemoarthrosis (bleeding into joints with subsequent contractures)
- Bleeding into muscle tissue
- Retroperitoneal bleeding
14
Q
Describe acute vs. chronic leukemias (in terms of naming conventions)
A
Acute = rapid increase in immature cells, generally seen in children and young adults
Chronic = Build-up of relatively mature but abnormal cells, generally seen in older adults
15
Q
Leukemia naming conventions: Lympho- = Myelo- = -blastic = -cytic =
A
Lympho- = Involves lymphoid or lymphatic system Myelo- = Bone marrow involving hematopetic stem cells -blastic = Large, immature cells -cytic = Mature, smaller cells
16
Q
Describe the difference between hemophilia and thrombocytopenia
A
Hemophilia = platelets could be normal, but you’re missing a factor in the clotting cascade, thereby putting you at risk for bleeding
Thrombocytopenia = low platelets, and therefore at risk for bleeding
17
Q
What data is displayed on a cardiac monitor?
A
BP (plus a # in parentheses = Mean arterial Pressure) PA (pulmonary artery) CVP (central venous pressure) A-line (arterial line) SpO2 Respiratory Rate
Other data:
- PWP: pulmonary wedge pressure
- CO: cardiac output
- CI: cardiac index
- SVR: systemic vascular resistance
- PVR: pulmonary vascular resistance
18
Q
A ___ is used to deliver medications or fluids. It is frequently called a __ as it used to be flushed by heparin. An air filter on the IV tubing for PFO is used to decrease the risk of __
A
PERIPHERAL IV
- Frequently called a HEP LOCK
- Air filter decreases risk of AIR BUBBLES
19
Q
A chest tube includes any tube placed into the chest. It acts to drain ___ in order to ___. How is the tube secured?
A
Chest tube drains BLOOD, FLUID, or AIR to REXPAND the LUNG. Tube is STITCHED into place and often placed to wall suction to facilitate drainage.
20
Q
Patients [can/cannot] mobilize with a chest tube. It is crucial to keep the drainage container [above/below] insertion site - why? If there is bubbling in the container, what might it indicate? If the chest tube pulls out, what do you do?
A
Patients CAN mobilize with a chest tube. It is crucial to keep the drainage container BELOW insertion site because it drains by GRAVITY. If there is bubbling in the container, it might indicate an AIRLEAK or a PNEUMOTHORAX, or in other systems may just indicate that the Chest tube is attached to SUCTION. If the chest tube pulls out, APPLY PRESSURE OVER SITE and TELL NURSE. If the chest tube is on wall suction, it needs a portable suction setup to mobilize pt.
21
Q
A pigtail catheter is placed in the __ or __ to ___. It has a [curved/straight] end to prevent ___ during insertion and a __ to allow controlled drainage. How does this impact PT?
A
A pigtail catheter is placed in the HEART or LUNG to DRAIN FLUID COLLECTIONS (e.g. tamponade or pericardial effusion, pleural effusion, etc.). It has a CURVED end to prevent PUNCTURE during insertion and a STOPCOCK to allow controlled drainage.
PT impact: consider the pathology requiring the pigtail (is it in heart or lung?) as it may impact cardiac output, ventilation, or gas exchange.
22
Q
___ promote LE circulation via air pumping through boots. They reduce the risk for __ in immobile populations. You should [keep them on/remove them] for PT mobility. What patients might you not want to use these with?
A
VENODYNE BOOTS
Reduce risk fro DVT in immobile patients.
REMOVE them for mobility
In confused patients, may want to NOT use them as a DVT prevention in order to reduce fall risk. Also if patient is very edematous, these may cause pitting edema, so consider alternate compression therapy
23
Q
Hemodialysis is a method for removing ___ from blood for patients in __ failure. Physicians surgically ananstamose the __ and ___ systems via a graft under the skin, allowing for indirect access to the [arterial/venous] system via a ___ or ___. This generally occurs for ___ (duration), ___ (Frequency).
PT implication: don’t do…?
A
Hemodialysis is a method for removing WASTE PRDUCTS from blood for patients in RENAL failure. Physicians surgically ananstamose the ARTERIAL and VENOUS systems via a graft under the skin, allowing for indirect access to the VENOUS system via a CENTRAL LINE or ARTERIOVENOUS FISTULA. This generally occurs for 3-4 HRS (duration), EVERY OTHER DAY (Frequency).
PT implication: DO NOT TAKE BP ON THIS SIDE!
24
Q
Similar to hemodialysis, ___ removes waste products continuously to eliminate large fluid shifts. PT treatment in these pts depends on __ and the location of the ___
A
Continuous venovenous hemofiltration (CVVH)
PT depends on MEDICAL STABILITY and the LOCATION OF THE LINE…if those are good, then you can mobilize
25
In a person on (esp. in one new to) dialysis, monitor for ___ response to activity. In a pre-dialysis patient, you're likely to see [increased/decreased] BP due to [increased/decreased] blood volume. In a post-dialysis patient, you're likely to see [increased/decreased] BP due to [increased/decreased] blood volume.
Monitor for HEMODYNAMIC response to activity.
Pre dialysis: INCREASED BP due to INCREASED blood volume
Post dialysis: DECREASED BP due to DECREASED BV
26
How does a VAC dressing work? Its goals are to... (3!)
System provides NEGATIVE PRESSURE (intermittent or continuous settings) to wound to approximate wound edges.
Goals:
- decrease edema
- increase perfusion
- promote granulation tissue formation
27
Patient has a VAC dressing. What do we do as PTs?
- Keep it attached?
- Can you disconnect it?
- Mobilize pt?
BEST to keep VAC attached to pt to promote healing
- most units have a battery back-up to allow for mobility
- if it needs to come off, get a nurse or an MD who is TRAINED to do it (it will likely require MD orders)
BUT consider implications of mobility on the wound: if it's a weight bearing surface, if there would be strong tensile forces through the wound if it's near a joint, etc.
28
What is a PICC line? What is it used for? What vein is it generally placed in? Where does the tip advance to?
PICC line = Peripherally inserted central catheter
- Used for extended antibiotics or medications, chemotherapy, or total parenteral nutrition (TPN)
- Usually placed in CEPHALIC, BASILIC, or BRACHIAL vein. The tip advances through large veins until it rests in SUPERIOR VENA CAVA or CAVO-ATRIAL JUNCTION (R atrium)
29
Potential complications of a PICC line
```
Catheter occlusion
Phlebitis
Hemorrhage
Thrombosis (remove with lytic agents)
Infection
```
*If tip of catheter advances too far into RA, it can cause arrythmias due to irritation of SA node
30
What are the PT implications when you see a PICC line? Why would you avoid taking BP over a PICC line? Can you exercise this arm?
Trace all IVs to origin and avoid pulling them out. Duh.
By taking BP over the PICC line, you could cause the tube to move and this could cause PHLEBITIS
You CAN exercise this arm!!
31
What are your options for surgical drains? How do they work? Do they impact PT treatment?
Tube placed in surgical/infection site to drain fluid. Many operate via a suction mechanism. Not much impact on PT treatment.
Options:
- Jackson-Pratt (JP) = Blake = Bulb Drain
- Hemovac
32
Options for auxillary feeding include ___, ___, and ___. Describe how each works and where the tubes go.
*In all of these, the stomach is working and pt CAN digest food!
```
Nasogastric tube (NG Tube)
- Tube placed through NARES and ESOPHAGUS into stomach
```
Gastric Feeding Tube (G-Tube) or Percutaneous Endoscopic Gastrostomy Tube (PEG)
- Tube placed THROUGH ABDOMEN directly into STOMACH
J-Tube
- Placed through abdomen into 1st part of JEJUNUM
- This is more of a permanent solution to feeding
33
When a patient is being fed via an auxillary feeding source, what do you need to consider if you must disconnect the feeding tube?
What to consider when mobilizing? When positioning?
Consider implications if pt has DM or labile blood sugars. Insulin dosing is based around how many calories they're getting, so may lead to HYPOGLYCEMIA
When mobilizing, SECURE the tube to prevent sheering or friction at insertion site and to decrease infection risk
Consider aspiration risk when positioning
34
What is a Foley Catheter?
| What do you do if it's full?
- Tube placed in bladder to drain urine
- Drains by GRAVITY: place it LOW when working with pt to promote drainage
- If it's full, have a caregiver empty it to prevent extra pulling
35
Diabetes is predicted to become the __th leading cause of death by the year __
7th leading cause of death by 2030
36
Cardiovascular disease is responsible for __% of deaths in pts with diabetes. What % of pts with diabetes have CVD?
CVD = 50-80% of diabetes deaths
20-25% of pts with diabetes have CVD
37
Diabetes is the leading cause of __, __, and __ failure
Blindness, amputation, kidney failure
38
Describe symptoms of DM1 vs DM2
DM1
- Frequent urination
- Unusual thirst
- Extreme hunger
- Unusual weight loss
- Extreme fatigue and irritability
* Accelerated atherosclerosis, decreased lifespan
DM2
- ANY of the type 1 symptoms
- Frequent infections
- Blurred vision
- Cuts/bruises that are slow to heal
- Tingling/numbness in hands/feet
- Recurring skin, gum or bladder infections
* Assoc highly with obesity
39
How is diabetes diagnosed? Provide normal and diagnostic values for lab tests.
HgA1c:
Diabetes =/> 6.5%
(normal 126 mg/dL
(normal 8 hours
Oral Glucose Tolerance Test:
2 hour plasma glucose > 200mg/dL
(normal <140 mg/dL)
40
Describe the Oral Glucose Tolerance Test
A baseline blood sample is drawn (time = 0). Pt is given measured dose of glucose solution to drink within a 5 min time frame. Blood is drawn at intervals to measure glucose (blood sugar) and sometimes insulin levels. The 2 hour sample is the most important one for simple diabetes test
41
Type 1 diabetes involves ___ destruction with a lack of ___. Type 2 diabetes involves ___ resistance with ___ deficiency. Gestational diabetes is generally a combination of __ resistance with ___ dysfunction, and generally peaks around ___ and goes away ___ (when?)
Type 1: BETA CELL distruction with LACK OF insulin
Type 2: INSULIN resistance with INSULIN deficiency
Gestational: COMBO of INSULIN resistance and BETA CELL DYSFUNCTION. Generally goes away when BABY IS BORN or turns into DM2. Peak onset is in 5th or 6th month
42
DM1 involves ___ destruction of ____ in the ____. What do these cells produce? Who is prone to DM1? What envirnmental factors may be involved? What are protective factors?
DM1: AUTOIMMUNE destruction of INSULIN PRODUCING BETA CELLS IN THE ISLETS OF LANGERHANS
Pts are likely genetically susceptible (but only about 33% contribution of genetics) and exposed ot environmental triggers:
- Maternal age >25
- Preeclampsia (dangeriously high BP during pregnancy)
- Neonatal respiratory dz
- Jaundice, especially due to ABO group incompatibilty
Protective factors: low birth weight, short birth length; viruses
43
DM2 accounts for __% of diabetes worldwide. It is __-__x more prevalent in people descendent from what? What should be emphasized clinically to prevent it? What are independent risk factors for DM2?
- DM2 = 90% of DM worldwide
- 2-6x more prevalent in African Americans, Native Americans, Pima Indians, and Hispanic Americans in US than in whites
- Focus on diet, weight loss, activity level, and smoking sessation
- Decreased insulin secretion and insulin resistance (decreased sensitivity to insulin in metabolic tissues [liver, skeletal muscle, adipose] results in insufficient insulin usage)
44
In DM2, ___ can impair beta cell fxn and exacerbate ___. This makes it difficult to tell how bad the ___ is. In short, we see [increased/decreased] insulin secretion in response to __ exposure. ___ do not adequately respond to blood glucose levels. Increased release of __ from the liver coupled with suppression of ___ by ___ results in [decreased/increased] glucose. Finally, __ receptors in the liver, skeletal muscle, and adipose are unresponsive (unable or resistant to using __).
In DM2, HYPERGLYCEMIA can impair beta cell fxn and exacerbate INSULIN RESISTANCE. This makes it difficult to tell how bad the HYPERGLYCEMIA is. In short, we see DECREASED insulin secretion in response to GLUCOSE exposure. BETA CELLS do not adequately respond to blood glucose levels. Increased release of GLYCOGEN from the liver coupled with suppression of INSULIN by GLUCAGON results in INCREASED glucose. Finally, INSULIN receptors in the liver, skeletal muscle, and adipose are unresponsive (unable or resistant to using INSULIN).
45
How does obesity play into DM2?
Obesity increases insulin resistance by releasing FREE FATTY ACIDS and CYTOKINES from adipose cells which disrupt insulin receptors on the target cell plasma membrane and prohibit insulin from facilitating the entry of glucose into the liver, muscle, and adipose tissue
46
What other body systems should be considered in DM treatment?
- Cardiovascular (microvascular and macrovascular disesase)
- Integumentary (skin checks)
- Musculoskeletal
- Sensory (neurologic)
- Visual (retinopathy)
- Renal
47
In ___, glucose binding to collagen and proteins in blood vessel walls (glycosylation) causes hardening and thickening of the ___. This leads to obstruction or rupture of the capillaries, which leads to necrosis and loss of function in tissues being supplied.
MICROVASCULAR DISEASE: glycosylation (glucose binding to proteins and collagen in vessel walls) results in hardening/thickening of BASEMENT MEMBRANE
48
In macrovascular disease, higher concentrations of __ in patients with DM lead to accelerated ___.
Macrovascular disease: higher LDL concentrations --> accelerated ATHEROSCLEROSIS
49
What is the protective sensation cutoff? Why is this important in DM?
Protective sensation = 10g of pressure, assessed via Semmes-Weinstein Monofilaments (5.07 monofilament). In peripheral neuropathy associated with DM, more uncontrolled blood sugar = worse risk for neuropathy. Daily skin checks are necessary to ensure no wounds
50
Wound healing in DM is complicated by __ and/or __
Peripheral artery disease
| Venous stasis
51
___ from macro and microvascular disease leads to tissue ___, and subsequently poor delivery of __ and __.
ISCHEMIA from macro and microvasc. disease --> NECROSIS and poor delivery of O2 and nutrients
52
__ is pain in legs when DM patient is walking. Why does this occur? What makes it better?
CLAUDIFICATION. Happens b/c ischemia: blood supply can't meet demand of peripheral muscles b/c pain. Goes away with REST b/c blood supply is restored
53
What is the relationship between peripheral artery disease and diabetic neuropathy?
Diabetes is frequently associated with PAD with atherosclerosis developing at a younger age in more distal arteries. Along with diabetic neuropathy, contributes to higher rates of non-healing ulcers and limb loss
54
Neuropathy associated with diabetes affects __, __, and __ nerves.
Neuropathy assoc. with diabetes affects SENSORY, MOTOR, and AUTONOMIC nn.
55
Labile blood sugars can also make DM patients prone to __. Describe the effect on WBC.
Labile blood sugars make pts more prone to IMMUNOSUPPRESSION. WBC are impaired without adequate glucose support and are unable to engulf and remove pathogens. Increased glucose also provides an optimal environment for some pathogens.
56
In DM, we also see impaired __ healing and poor quality __ tissue and __ accumulation. Risk of amputation in DM is __-__x greater than in non-DM patients
DM: impaired BONE healing, poor quality GRANULATION tissue and COLLAGEN accumulation. Risk of DM amputation is 15-40x greater compared to non-DM pts.
57
What is silent ischemia DM? Denervation of what might contribute to this?
In diabetic patients, they may not have pain with ischemia (heart attack) due to reduced sensation.
AUTONOMIC DENERVATION contributes to abnormal/lack of sensation. Correlated with Circadian rhythms in setting of increased myocardial O2 demand at this time (happens in morning most often)
58
Why might we see hypoglycemia or hyperglycemia with exercise?
HYPOglycemia: due to decreased foot intake, rapid absorption of insulin @ injection site and exercising at peak insulin effect
HYPERglycemia: if there is an insulin deficit and hyperglycemia @ the onset of exercise, the muscle is unable to uptake insulin and the liver produces more glucose, thereby increasing the hyperglycemia
59
Blood vessel abnormalities occur in DM with atherosclerosis via damage to the ___ membrane. HTN is __x more likely in DM.
Blood vessel abnormalities due to Damage to BASEMENT CAPILLARY MEMBRANE
HTN 2x as likely in DM
60
In the presence of autonomic dysfunction in DM, resting HR is [elevated/decreased]. Pts tend to be [hypo/hyper]tensive with exercise and [hyper/hypo] tensive after exercise. In DM, we see a blunted __ response; these pts reach anerobic metabolism at [higher/lower] HRs.
In the presence of autonomic dysfunction in DM, resting HR is ELEVATED. Pts tend to be hypertensive with exercise and HYPOtensive after exercise. In DM, we see a blunted HR response; these pts reach anerobic metabolism at LOWER HRs.
61
Give normal plasma glucose levels for children, adults, and adults >60
Child: 60-100 mg/dL
Adult: 70-100 mg/dL
Adult >60: 80-110mg/dL
62
Give normal hemoglobin A1c levels
Normal: 4.0-6.0%
Good: 2.5-5.9%
Fair: 6.0-7.0%
Poor: >7.0%
63
If you increase activity in someone in a hypoglycemic state, what will happen?
Activity requires glucose, so with low glucose levels, they will CONTINUE to decrease
64
If you increase activity in someone in a hyperglycemic state, what will happen?
If BS is high, no insulin is available to assist with metabolism. If you exercise, you will INCREASE blood sugar levels and progress toward KETOACIDOSIS due to metabolism occurring with activity.
65
Diabetic ketoacidosis (DKA) occurs with a [gradual/sudden] onset. Describe symptoms
```
DKA= GRADUAL onset
Thirst
Hyperventilation
FRUITY odor to breath
Lethargy/confusion
Coma
Muscle/abdominal cramps
Polyuria, dehydration
Flushed face, hot/dry skin
Elevated temperature
Blood glucose >300mg/dL
pH <7.3
```
66
Hyperglycemic states occur via [gradual/sudden] onset. Describe symptoms
```
GRADUAL onset
Thirst
Polyuria
Volume loss
Severe dehydration
Lethargy/confusion
Seizures
Coma
Abdominal distention & pain
Blood glucose >300 mg/dL
```
67
Hypoglycemic states occur via [sudden/gradual] onset. Describe symptoms.
```
SUDDEN onset
Pallor
Perspiration
Irritability/nervousness
Weakness
Hunger
Shakiness
Headache
Double/blurred vision
Slurred speech
Fatigue
Numbness of lips/tongue
Confusion
Convulsion/coma
Blood glucose <70 mg/dL
```
68
What musculoskeletal pathologies are associated with DM at the hand/wrist?
- Carpel tunnel (up to 20% DM pts, and 75% of pts if known joint impairments...due to CT changes with DM)
- Dupuytren's Contracture (16-42% of pts with DM; prevalence increases with age and length of DM, but NOT associated with metabolic control of DM)
- Trigger Finger (5-20% pts with DM1 or 2; associated with length of time of DM. NOT associated with metabolic control of DM)
- Diabetic sclerodactyly (thickening/waxiness of skin on dorsum of fingers)
- Complex regional pain syndrome (reflex sympathetic dystrophy)
69
What musculoskeletal pathologies are associated with DM at the shoulder?
- Adhesive capsulitis (19-29% of pts with DM, 5% in controls. Increased age, longer duration of DM. NOT capsular pattern, but instead we see global tightness where limitations in ER=IR)
- Calcific tendinitis (calcium deposits in tendon)
70
What is Charcot's foot?
Diabetic neuropathy arthropathy = Charcot's foot
Loss of sensation & blood supply leads to repated trauma and joint destruction, stress fx, torn ligaments, and subluxation of tarsal and metatarsal joints. Risk for ulcers with abnormal WB. Custom shoes help to decrease WB. Fusion is an option too.
71
Describe the time frames for fast, short, intermediate, and long-acting insulin
Fast: onset within 10-20mins, last 30-90mins
Short: onset within 30-60 mins, last 2-5 hrs
Intermediate: onset 1-2 hrs, last 4-12 hrs
Long: onset 30mins - 3 hrs (usually 1-2 hrs), peak at 10-20 hrs
72
General areas on the body for insulin injection
Abdomen (front and sides), triceps, glut max, lateral quads
73
If a patient has retinopathy secondary to DM, consider avoiding what exercise activities? Recommend what exercise types?
Consider avoiding:
Strenuous activities
Valsalva maneuver
Pounding/jarring activities
```
Recommend:
Low impact cardio
Swimming
Walking
Stationary bike
```
74
If a pt has loss of protective sensation secondary to DM, regarding exercise, consider avoiding...
Recommend...
```
Consider avoiding:
Jogging
TM
Long distance walking
Step exercise
```
Recommend:
Swimming
Biking
Rowing
75
A patient starts a vigorous exercise program between 9-10pm. Her blood glucose is 124 before dinner, 145 before racquetball, 138 before bedtime. She awakens at 2AM with a severe hypoglycemic reaction. Why did this occur?
Muscles deplete glycogen stores during exercise. For several hours post exercsie, they take up glucose to replenish glycogen stores, thereby lowering blood glucose level. To minimize the risk of hypoglycemia, she should reduce her dose of insulin before her evening meal and take a larger than usual bedtime snack.
76
Most common complication with burns?
Pneumonia (6.1% of patients)
77
What are criteria for referral to a burn center?
1. Partial thickness burns >10% TBSA
2. Burns involving face, hands, feet, genitalia, perineum, major joints
3. Full thickness burns in any age group
4. Electrical burns
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting illness that affect care 8. Patient with burns & concomitant trauma (i.e. fractures)
9. Children with burns in a hospital without qualified personnel or equipment to meet care needs
10. Burn injury in a patient who will require special social, emotional, or rehabilitative intervention
78
Functions of skin (6!)
Cosmetic appearance
Temp regulation (secretes sweat & electrolytes)
Vit D synthesis (needed for bone growth & calcium absorption)
Protection from infection
Skin lubrication via oil secretion
Sensation
79
Which skin layer contains melanocytes?
Epidermis
80
What is the region between the epidermis and dermis that consists of an extensive series of epidermal-dermal ridges & valleys to increase surface area, act as a reservoir, and overcomes frictional forces skin is exposed to?
Rete peg region
81
The dermis is the deepest layer of skin and is __-__x thicker than the epidermis.
Role: __ and ___. It contains...
It has 2 layers...
Dermis is 20-30x thicker than epidermis. Role: strength & elasticity
Contains blood vessels, lymphatics, nerves, collagen, and elastic fibers. Sweat ducts, sebaceous glands, and hair follicles are enclosed here
2 layers: superficial papillary level (papillary ridges to increase SA between dermis and epidermis --> fingerprints), deep retinacular layer
82
Causes of burn injury (Categories)
Thermal (flame, liquid, steam, hot object)
Chemical (contact, ingestion, inhalation, injection)
Electrical (contact w/wiring, lines, lightning)
Radiation (exposure to radioactive source)
83
The vast majority of burns are due to what type of injury?
```
44% flame/fire injury
33% scald injury (most prevalent in kids under 5yo)
9% contact with hot objects
4% electrical injury
3% chemical injury
```
84
Severity of a burn depends on 4 factors
Temperature of source
Contact length of time
Thickness of the skin
Area of burn injury
85
Why are older patients (>65yo) more susceptible to deeper burns?
After age 65, turnover rate of epidermis decreases by 50%, epidermis thins, rete peg region flattens, fewer epidermal-lined skin appendages are present, decrease in collagen content, decrease in vascularity
86
What's the Lund/Browder Classification? What is the Rule of Nines?
Lund/Browder: Estimate of burn size and depth. Helps to make a determination of severity, prognosis, and deposition of a patient.
Rule of Nines: divides body surface into areas that are 9% or multiples of 9%. Used for a quick estimate of total body surface area burned. Head = 9%, legs = 18%...these are different in kids b/c their proportions are different!
87
Describe the 5 burn classifications
```
Superficial (1st deg)
Superficial Partial-Thickness (2nd deg)
Deep Partial-Thickness (2nd deg)
Full-Thickness (3rd deg)
Subdermal (3rd deg)
```
88
```
Describe superficial burns.
Depth
Presentation
Pain
Healing time
```
Depth: Epidermis only
Presentation: Red, dry skin
Pain: Tender to touch
Healing time:
89
```
Describe superficial partial-thickness burns.
Depth
Presentation
Pain
Healing time
```
Depth: Epidermis & Partial dermis (papillary)
Presentation: Intact blisters, red, blanching to touch
Pain: Extremely painful
Healing time:
90
```
Describe deep partial-thickness burns.
Depth
Presentation
Pain
Healing time
```
Depth: Epidermis & dermis (papillary & reticular)
Presentation: Mixed red or waxy white, sluggish capillary refill, marked edema, hair follicle preservation
Pain: less intense (superficial nerve endings injured)
Healing time:
91
```
Describe a full-thickness burn.
Depth
Presentation
Pain
Healing time
```
Depth: Epidermis & dermis, some subcutaneous fat
Presentation: hard, parchment-like eschar, black, deep red, white, hair follicles completely destroyed
Pain: None (nerve endings destroyed in area, but generally theres' some partial/superficial burns adjacent that will be painful)
Healing time: REQUIRES SURGERY
92
What is eschar?
Devitalized/dead tissue consisting of desiccated clot of plasma and necrotic cells. Feels dry, leathery, rigid.
93
```
Describe a subdermal burn.
Depth
Presentation
Pain
Healing time
```
Depth: Epidermis, dermis, subcutaneous tissue
Presentation: necrosis of muscle and/or bone
Pain: None
Healing time: Requires EXTENSIVE surgery
*4th Degree burn. Extensive surgery and reconstruction if not amputation. This depth of burn is more frequent with electrical burns.
94
Electrical burns follow the path of [greatest/least] resistance. Give that order in terms of tissue resistance
```
LEAST resistance
Nerves
Blood vessels
Muscle
Skin
Tendon
Fat
Bone
```
95
As electricity travels through the body, electrical energy is converted into __ in direct proportion to the ___ and ___. High resistance in the victim's body causes harm.
Electrical energy is converted into HEAT in direct proportion to the CURRENT and ELECTRICAL RESISTANCE
96
Severity of injury is [directly/inversely] proportional to the cross-sectional area of the body part involved.
Severity is INVERSELY proportional to cross sectional area of involved body part. Most severe injuries seen at wrist and ankle. (more heat with less dissipation)
97
Complications from electrical burns include...
Cardiac arrythmias including ventricular fibrulation, renal failure assoc with kidney shock, trauma
98
In electrical burns, is the ENTRY or EXIT wound more significant?
EXIT wounds are more significant
99
What are the vascular responses following cold injuries? Describe mechanisms for frostbite
Initial vascular response: vasoconstriction to protect from a drop in core temp, but this decreases skin temp. 2 mechanims cause tissue injury in frostbite:
1. Drop to 35.6*F ice crystals form in extracellular spaces and then intracellular spaces. They result in expansion and mechanical destruction
2. Cold induced vasoconstriction and direct endothelial injury occur initiating fibrin deposition, platelet aggregation, and release of local and systemic mediators. Thrombosis occurs and leads to further ischemia and propogation of this.
With thawing, there is increased capillary permeability and an aggregation of RBC and microvascular occlusion
100
What does frostbite look like? What's its average demarcation period?
White plaque, clear blisters, hemorrhagic blisters, or necrosis
~3wk demarcation period but could take months for necrotic appearing tissue to show improvement and survive. Surgical debridement is DELAYED with frostbite b/c tissue may really still be alive.
101
Long term effects of frostbite?
Increased cold sensitivity, burning/tingling on reexposure to cold, increased sweating of affected area
102
Describe the 3 burn wound zones
Zone of coagulation
- Cells irreversibly damaged, skin death, equal to full-thickness burn w/need for grafting to heal
Zone of stasis
- Injured cells that may die within 24-48h. Potential conversion of salvageable tissue into necrotic tissue, thereby enlarging zone of coagulation. Wound infection, drying, or inadequate perfusion will result in conversion (SO you can minimize damage with proper fluids/care)
Zone of hyperemia
- Site of minimal cell damage, tissue should recover with no lasting effects
103
Describe escharotomy and fasciotomy.
Can you do PT?
Escharotomy
- Burn eschar is destroyed, nonelastic, and nonviable. If the injury is circumferential, inelasticity combined with edema produces tourniquet effect. Increased tissue pressures >30mmHg cause tissue necrosis, SO a surgical incision is made through eschar. If pulses return (assessed w/Doppler ultrasound), great! If not...
Fasciotomy
- No pulse return with escharotomy so they deepen incision through fascia to decrease pressure.
NO CONTRAINDICATION with exercise! You can still do ranges, exercise, etc. but watch where your hands are.
104
What is the goal with skin grafting?
Resurface burns that are not expected to reepithelialize within 14-21 days. Must first remove all injured tissue (debridement)
105
Describe the different types of skin grafts.
With non-permanent grafts (all but autograft), you can start ROM sooner.
Xenograft - pigskin, temporary coverage of closed wounds, does NOT vascularize but will adhere to a clean superficial wound. Pain control while wound heals
Allograft - CADAVER, biological dressing for TEMPORARY wound closure when autograft isn't immediately available. Reduces water loss, prevents wound desiccation, reduces heat loss, suppresses microbial proliferation, stimulates neovascularization. Usually rejected by host within 3-4 wks
Skin substitute - artificial dermal matrix which encourages new groth of dermal matrix. Generally only used on LARGE body burns to prep dermal matrix to accept an autograph. You can still do ROM during skin substitute. TEMPORARY
Autograft - ONLY permanent graft. From person's own skin, generally from buttocks, back, thighs. Heal by re-epitheliazation. If it takes, you can start ROM after 7-10 days.
106
What's a dermatome?
instrument used to remove skin graft from donor site. MD harvests it to a desired size and depth
107
When taking a skin graft, describe the different thicknesses you can have and advantages of each.
Split-thickness: epidermis and superficial layers of dermis
Full-thickness: full dermal thickness, leaves a full-thickness wound that will require either primary closure or grafting with a split-thickness skin graft. Resembles normal skin more closely including texture, color, hair growth potential
Thinner graft = better adherence (but contracts more)
Thicker graft = better cosmetic result
108
What are the advantages to a meshed versus sheet graft?
Mesh: limited donor site available, skin is hashed to let it expand to wound bed (up to 2-3x original size). The openings heal via reepitheliazation.
- Mesh contracts more than sheet, not as pretty cosmetically b/c hashes (AKA piecrust). These also help drainage. It does take better than a sheet graft.
Sheet graft: skin graft without alteration after it is harvested - face, neck, hands are covered with this so it'll be pretty.
109
Complications of burn injury (8)
Infection
- Leading cause of mortality from burns
Pulmonary
- inhalation injuries suspected with singed nasal hair, resp. distress, facial edema, hoarseness, etc.
Metabolic
- Incr. met. demands -->decr. body weight and decr. energy stores
Cardiovascular
- Shift in fluid to interstitum (out of blood vessels) --> decreased cardiac output
Neuropathy
- inappropriate splinting, ulnar n compression
Pathological scars
- contractures, hypertrophic scars
Delirium
- maybe b/c meds for burn treatment, but assoc with worse clinical outcomes and cognitive impairment
Heterotropic Ossification (abnormal bone growth around joint)
110
What is heterotopic ossificans? What joints are most commonly affected?
HO: formation of organized bone. Painful, swelling, and warmth at joint. Can be made WORSE with aggressive ROM. Must be treated surgically. Assoc with TBSA >20%
Joints: elbow, shoulder, hip (in that order)
111
The __ phase of burn treatment occurs 24-72h after injury. Ends when capillary integrity returns to near-normal and large fluid shifts have decreased (fluid balance).
EMERGENT/Resuscitation Phase
112
In the emergent phase of burn treatment, PT goals are to ___.
PT: perform eval within 24-48h after admission. Minimize edema (develops 8-12h after injury), optimal positioning, initiate motion, maintain soft tissues in elongated state. Static orthoses may be used to counteract edema, support extremities. ROM in this phase is done to preserve ROM, muscle function.
113
The ___ phase of burn treatment occurs 48-72h post injury and ends at ____. What are PT goals here?
Acute Phase. 48-72h post injury until wound closure.
- Wound closure defined as either surgical closure or secondary intention healing.
PT goals: preserve or increase ROM, preserve tendon gliding, maintain muscle activity, inhibit contraction, promote fxn
114
The ___ phase of bone healing last from graft adherence or wound closure until scar maturation. PT goals are...
Rehabilitation phase
PT goals: protect new spontaneously healed wound or fragile graft. Preserve joint mobility, increase strength/fxn, inhibit scar contraction or hypertrophy
115
PT positioning of burn patient begins in the ___ phase and continues through ___
PT positioning begins in EMERGENT phase and continues into acute and rehab phases. Contractures may be defined as shortening of soft tissues, incl skin, muscle, tendon, ligament, and fascia which may restrict full ROM. Longer burn stays open, the longer the inflammation process lasts. This results in progressive scar formation and restricted motion
116
How do you position neck, shoulder, elbow, and hand after burn?
Neck: anterior neck burn should be placed in extension. Circumferential/ posterior/ asymmetrical neck burn should be placed in neutral toward extension. Do NOT use a pillow which would push head down and encourage neck burn contractures
Shoulder: abduct arm to 90-110*, supported on arm troughs
Elbow: keep in extension with
117
How do you position the hip, knee, and ankle after a burn?
Hip: extension, head of bed flat, use a trochanter roll to maintain neutral rotation
Knee: place in extension as to not result in a flexion contracture
Ankle: neutral, avoid inversion/eversion suspend heels to prevent ulcer. Ankle equinus (achilles shortening, gastroc soleus tightness) is frequent and can lead to contractures. Prevent by keeping foot in neutral or slightly dosiflexed
118
Scar formation is related to...
```
Size of injury
Depth of injury
Location of burns (e.g. across a joint)
Time needed for complete wound closure
Timing of surgical intervention
Type of surgical intervention/graft
```
119
What are the four characteristics of a burn scar?
Pigmentation
Fascularity
Pliability
Scar height
120
Scars over [concave/convex] surfaces meet less resistance, allowing greater migration of scar and webbing. Give an example.
Scars over CONCAVE surfaces --> less resistance.
E.g. axillary contractures, flexion contractures in antecubital surface of elbow
121
Describe the collagen in a hypertrophic scar
The extracellular matrix consists of more collagen, thinner collagen, and more disorganized collagen than in normal skin.
122
Burn wounds healing >/= ___ days should be assessed for pressure garments. Recommended to wear garment for __-__h/day with pressure between __-__mmHg until scar maturation.
Burn wounds healing >/= 14 days should be assessed for pressure garment. Recommend to wear 18-24 h/day with pressure between 24-40mmHg until scar maturation
123
When can you start to integrate scar massage after a burn? How long and how frequently do you do it?
Once scar has matured enough to tolerate sheering forces. It remodels and softens scar tissues by freeing fibrous bands and encourages elasticity thereby improving mobility. Massage in slow, firm manner for 5-10mins, 3-6x daily
124
When can exercises be safely initiated following a burn injury?
First 48h! Remember that a graft needs ~7 days to heal (an autograph), but they won't get a graft right away, so you can start exercise pre-graft! Do functional activities as SOON as pt is awake enough to participate. Similarly, ambulation can begin ASAP after admission if pt is medically stable. Reduces clot risk, prevents decubiti, maintains LE ROM, maintains strength/ endurance/ conditioning
125
After a burn, edema forms within __ h and peaks at __ h
Edema within 8-12h, peaks at 36h
126
Phases of emotional recovery post burn
Admission: shock, helplessness
Recuperation: in-hospital, difficulty adapting, grief
Reintegration (at discharge): anxiety, fear
Rehabilitation (post discharge): delayed grief, body image concerns, PTSD, wear on caregivers
127
Variables affecting return to work/school post burn
```
Size, location, severity of burn
Pain
Duration of hospitalization
Physical impairment
Psychosocial difficulties
Prior employment
Environmental impediments
Lack of vocational training
```
128
```
Give examples of the following as they relate to immunity:
Excessive responses
Inadequate responses
Inappropriate responses
Overwhelmed responses
```
Excessive - allergies
Inadequate - AIDS and cancer
Inappropriate - auto-immunity
Overwhelmed - septic shock
129
What's the difference between innate and adaptive immunity?
Innate
- 1st line of defense
- Nonspecific, immediate, rapid
Adaptive
- 2nd line of defense
- Specific, slower
- Targeted: more efficient and effective
- Learned response
130
Passive immunity is [long/short] lived and is [acquired/transferred}. Describe examples.
Passive immunity is SHORT lived, lasts a few weeks or months and goes away. It is transferred, e.g. from maternal to fetus, or from an injection (hyperimmune or gamma globulin injections)
131
Active immunity is [long/short] lived. It involves ___ cells. It is [acquired/transferred]
Active immunity is ACQUIRED (via immunization or disease), LONGER lived, and involves memory B CELLS and T CELLS. In active immunity, the body makes its own antibodies
132
Define infectious disease. What is colonization? What is a host?
Infectious disease = presence and multiplication of a living organism on or within a host
Colonization: presence of microbes that are NOT harmful
Host: any organism capable of supporting the nutritional and physical growth requirements of another organism
133
Infections are __ when the infectious agent can be transmitted directly or indirectly to a new host
COMMUNICABLE
134
Describe the chain of infection (6 phases)
```
Causative agent
Reservoir
Portal of exit
Mode of transmission
Portal of entry
Susceptible host
```
135
Causative agents include...(5)
- Bacteria (generally not pathogens; unicellular, no nucleus)
- Viruses (TINY particles, need a host to reproduce, not quite a life form)
- Fungi (usually harmless unless the host is compromised, eg CA or HIV. Not a plant or an animal)
- Prions (protein particle that lacks a genetic code but replicates and produces disease. Most common in brain and --> neuro disorders)
- Parasites (worms, protozoa, etc. Not as common as prions. Looks like little strokes on MRI b/c worm is eating your brain! Gross)
136
A ___ is where a pathogen lives and multiplies such that it can be transmitted to a susceptible host. Examples include...
RESERVOIR.
| Eg. patients, staff/visitors, soil (plants), raw/undercooked meat, water
137
A ___ is how a causitive agent exits the reservoir including via body fluids and shedding of skin.
PORTAL of EXIT
138
A ___ is how the microbe enters the host. Examples include...
Portal of ENTRY.
E.g. Maternal, respiratory, skin and mucus membrane, parenteral (ie via veins), enteral (ie via GI tract - eat something infected)
139
What determines the susceptibility of a host?
- Prior immunity
- Disruption of natural barriers (e.g. skin wound)
- Presence of invasive or prosthetic devices (e.g. PICC line, total knee replacement)
- General immune status
140
What factors can compromise the immune system?
Age (older = sick more easily)
- Chronic dz
- Medications (e.g. chemo, transplant meds, steroids)
- Immunodeficiency (HIV, congenital disorders)
- Immune compromised vs competent
- ---> Compromised: unable to work at full capacity
- ----> Competent: able to produce normal immune response
141
Describe the 5 steps in the course of infection
1) Incubation (active replication)
2) Prodrome (start of symptoms)
3) Acute phase (max disease)
4) Convalescence (recovery & containment)
5) Resolution
142
When do you use hand hygiene?
ALWAYS! Duh.
- Before pt contact
- After contact with patient's skin, contact with bodily fluids/excretions, intact skin, wound dressings
- After removing glvoes
143
Use soap and water when...
- Hands are visibly dirty, contaminated, soiled
- After using bathroom
- Before eating
- Pt with c-diff, anthrax, ebola
Wet hands with water, soap, rub for at least 15s. Rinse and dry with disposable towel.
144
Use an alcohol-based hand rub when...
Hands are NOT visibly soiled
| - Apply to palm of one hand, rub until dry. Volume is based on manufacturer
145
With ___ precautions, pathogens can spread through enviornmental contamination. E.g. = MRSA, norovirus, vancomycin resistant enterocccus. You should wear ___ for pt interactions.
CONTACT precautions spread through enviornmental contamination
Gown + gloves. Take them off after you exit. Pts in one room or cohorted together
146
With ___ precautions, we see a nosocomial infection that occurs due to antibiotic exposure. This is prevalent in acute care hospitals and LTAC. E.g. c-diff.
You should wear...
You should wash your hands with...
You should clean your equipment with...
Contact Plus
Gloves + gown
Wash with SOAP AND WATER then use ALCOHOL BASED rub
Clean equipment wtih BLEACH (not virex!)
147
With __ precautions, pathogens can be transmitted and remain infectious over long distances while suspended in the air. Eg. TB and chicken pox. These pts are in a __ room. You should wear ___. Pts should wear __ when leaving th eroom.
AIRBORNE
Negative pressure room is used
You should wear a N95 mask or respirator donned BEFORE entering room
Pt should wear surgical mask when leaving room
148
With __ precautions, pathogens are spread through close (
DROPLET
Single patient room
You should wear a MASK (respirator is not necessary)
Pt should wear a respirator mask if tolerated outside of room
149
Normal WBC values
4,500-11,000 cell/mm3
150
Normal RBC values
Male: 4.5-5.3 x10^6 /mm3
Female: 4.1-5.1 x10^6 /mm3
151
Normal Hgb values
Male: 13-18 g/dL
Female: 12-16 g/dL
152
Normal Hct values
Male: 37-49%
Female: 36-46%
153
Normal Plt values
150,000 - 450,000 cells/mm3
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