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Nurs 263 Exam 3 > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

Burns are the 2nd leading COD for which age group.

A

Kids (18 and under)

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2
Q

3 concepts r/t tissue integrity

A
  • infection
  • immunity
  • mobility
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3
Q

Injury caused by exposure to heat, chemical, radiation, electricity or extreme cold.
-Effect can last 2-3 days.

A

Burns

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4
Q

Exposure to this causes microvascular & inflammatory responses w/in minutes of injury. Causes fluid, electrolytes & proteins to leak into interstitial space

A

Thermal Burns

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5
Q

This is usually limited to injured tissue with smaller burns and noninjured tissue in larger burns.

A

Burn edema

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6
Q

Fluid shift from intravascular to interstitial spaces in thermal burns may cause what?
-Also, fluid loss from wound

A

hypovolemic shock

AKA: BURN shock

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7
Q

Types of chemical burns.

A
  • Acid
  • Alkali
  • Organic
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8
Q

Acid burns cause what type of substance to form

A

Eschar - results from coagulation necrosis.

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9
Q

What is the purpose of eschar

A

prevent continued tissue damage beneath layer of eschar.

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10
Q

This type of burn causes protein liquifaction and produces a soupy wound.

A

Alkali chemical burn

-ammonia, lime

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11
Q

Protein liquifaction produces what kind of damage.

A

Continuing tissue damage to deeper structures.

-Occurs rapidly & continues until pH is corrected.

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12
Q

This chemical burn produces a thermal component & may be absorbed systemically producing renal & hepatic toxicity.

A

Organic chemical burns

-Phenols

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13
Q

This type of chemical burn can cause direct lung injury

A

Inhalation

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14
Q

Burns caused by electrical currents

A

Electrical burns

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15
Q

Type of electricity that is high voltage for an instant.

  • Entrance - Exit wounds
  • May cause arrest, LOC, temp paralysis, nerve damage, seizure, burns from metal.
A

Direct Current (DC)

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16
Q

Type of electricity that causes tetanic muscle contractions.

  • May inhibit respiratory efforts.
  • “clamp down” increases duration of exposure.
A

Alternating current (AC)

17
Q

Involves epidermis only.
Example is a sunburn.
-Erythema, minimal edema, pain
-Heals in 3-5 days

A

Superficial burn

18
Q

Involves epidermis and superficial layer of the dermis.

  • Brief contact with hot objects.
  • Moderate edema, very painful
  • Blisters, moist.
  • Heals 10-14 days
  • No scarring
A

Superficial partial-thickness burn

19
Q

Involves epidermis, dermis & subcutaneous layer.

  • Exposure to flame, electricity or chemicals.
  • Dry, leather, white
  • Absent cap refill
  • Skin grafting
  • Heals via contraction & granulation tissue formation
  • Scarring & hyper pigmentation
A

Full-thickness burn

20
Q

Involves epidermis & deep layer of dermis.

  • Tar burn, hot liquid, radiation, …
  • Erythematous or pale, slow/absent cap refill
  • Edema & altered sensation
  • Heals 2-3 weeks
  • may require skin graft
  • scarring & hyperpigmentation
A

Deep partial-thickness burn

21
Q

Involve all layers of skin & may include injury to muscle, tendons or bone.

  • Prolonged contact w/ flame, hot objects or electricity
  • Charred dry appearance
  • Skin grafting or Amputation
A

Subdermal burns

22
Q

Area of wound that blanches with pressure & will heal in 7-10 days.

A

Zone of hyperemia

23
Q

Innermost area of wound that is nonviable tissue

A

Zone of coagulation

24
Q

Area of wound that can easily convert to either nonviable tissue if blood flow is not adequately returned.
-Area that is on the fence of good and bad.

A

Zone of stasis.

25
Q

How to prevent zone of stasis from being non-viable?

A

Proper fluid resuscitation

26
Q
  • outpatient treatment, teaching
  • monitor for dehydration
  • mild analgesics
A

Minor Burn treatment

27
Q

Stages of care of severe burns

A
  • Emergent / Resuscitative
  • Acute stage
  • Rehabilitation
28
Q
  • First aid
  • fluid resuscitation
  • transfer??
A

Emergent / Resuscitative

29
Q
  • wound care
  • nutrition therapy
  • infection prevention
  • pain management
A

Acute stage

30
Q
  • Begins w/ wound closure - ends w/ highest level of health restoration
  • Prevent contractures, scars
  • Resumption of work, family role
  • ROM to enhance mobility
A

Rehabilitative stage

31
Q

Phase that lasts up to 48-72 hours after injury

  • burn shock w/ cardiovascular collapse
  • identify & treat concurrent injuries
  • Primary & secondary assessments for traumatic injury
A

Resuscitative phase

32
Q

Emergency & Acute care for burns:
Nursing / medical care
AIRWAY

A
  • Elevate HOB 30
  • Suction
  • Intubation PRN
  • Humidify O2
  • Bronchodilators
  • Monitor carboxyhemoglobin levels
  • Pain meds
33
Q

Emergency & Acute care for burns:
Nursing / medical care
CIRCULATION

A
  • Restore blood volume w/ fluid resuscitation
  • crystalloid fluids (NS, LR) (2 large bore IVs)
  • Hourly urine output
  • hemodynamic monitoring (invasive)
34
Q

Initial wound care

A
  • stop burning process
  • water lavage
  • elevate burned extremities
  • HOB elevated
  • Tetanus prophylaxis
  • Escharotomy
35
Q

-Supraglottic
-From heat (mucosa) or chemicals in water
thermal burn - isolated to supraglottic
-TX 100% O2
-Edema peaks 48 hours

A

Upper-airway injury

36
Q
  • Injury below glottis

- composition and amount of inhaled substance

A

Inhalation injury

37
Q
  • Result of toxic gases & chemicals in inhaled smoke
  • Hopoxemia & pulmonary dysfunction
  • Respiratory failure
  • S/Sx onset unpredictable
  • Tx is supportive
  • Parenchymal lung injury
A

Lower airway injury

38
Q

S/Sx of pain on passive stretching of muscle, decreased sensation, weakness, swelling, pain beyond expectations for the injury.

A

Compartment syndrome.

39
Q

Guidelines for escharotomy

1: what pressure
2: doppler pulses

A

1: pressures greater than 40 mmHg
2: pulses absent in distal arteries

Nurs 263 Exam 3 (3 decks)

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