Tissue Integrity Flashcards
Burns are the 2nd leading COD for which age group.
Kids (18 and under)
3 concepts r/t tissue integrity
- infection
- immunity
- mobility
Injury caused by exposure to heat, chemical, radiation, electricity or extreme cold.
-Effect can last 2-3 days.
Burns
Exposure to this causes microvascular & inflammatory responses w/in minutes of injury. Causes fluid, electrolytes & proteins to leak into interstitial space
Thermal Burns
This is usually limited to injured tissue with smaller burns and noninjured tissue in larger burns.
Burn edema
Fluid shift from intravascular to interstitial spaces in thermal burns may cause what?
-Also, fluid loss from wound
hypovolemic shock
AKA: BURN shock
Types of chemical burns.
- Acid
- Alkali
- Organic
Acid burns cause what type of substance to form
Eschar - results from coagulation necrosis.
What is the purpose of eschar
prevent continued tissue damage beneath layer of eschar.
This type of burn causes protein liquifaction and produces a soupy wound.
Alkali chemical burn
-ammonia, lime
Protein liquifaction produces what kind of damage.
Continuing tissue damage to deeper structures.
-Occurs rapidly & continues until pH is corrected.
This chemical burn produces a thermal component & may be absorbed systemically producing renal & hepatic toxicity.
Organic chemical burns
-Phenols
This type of chemical burn can cause direct lung injury
Inhalation
Burns caused by electrical currents
Electrical burns
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.
Direct Current (DC)
Type of electricity that causes tetanic muscle contractions.
- May inhibit respiratory efforts.
- “clamp down” increases duration of exposure.
Alternating current (AC)
Involves epidermis only.
Example is a sunburn.
-Erythema, minimal edema, pain
-Heals in 3-5 days
Superficial burn
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
Superficial partial-thickness burn
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
Full-thickness burn
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
Deep partial-thickness burn
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
Subdermal burns
Area of wound that blanches with pressure & will heal in 7-10 days.
Zone of hyperemia
Innermost area of wound that is nonviable tissue
Zone of coagulation
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.
Zone of stasis.
How to prevent zone of stasis from being non-viable?
Proper fluid resuscitation
- outpatient treatment, teaching
- monitor for dehydration
- mild analgesics
Minor Burn treatment
Stages of care of severe burns
- Emergent / Resuscitative
- Acute stage
- Rehabilitation
- First aid
- fluid resuscitation
- transfer??
Emergent / Resuscitative
- wound care
- nutrition therapy
- infection prevention
- pain management
Acute stage
- Begins w/ wound closure - ends w/ highest level of health restoration
- Prevent contractures, scars
- Resumption of work, family role
- ROM to enhance mobility
Rehabilitative stage
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
Resuscitative phase
Emergency & Acute care for burns:
Nursing / medical care
AIRWAY
- Elevate HOB 30
- Suction
- Intubation PRN
- Humidify O2
- Bronchodilators
- Monitor carboxyhemoglobin levels
- Pain meds
Emergency & Acute care for burns:
Nursing / medical care
CIRCULATION
- Restore blood volume w/ fluid resuscitation
- crystalloid fluids (NS, LR) (2 large bore IVs)
- Hourly urine output
- hemodynamic monitoring (invasive)
Initial wound care
- stop burning process
- water lavage
- elevate burned extremities
- HOB elevated
- Tetanus prophylaxis
- Escharotomy
-Supraglottic
-From heat (mucosa) or chemicals in water
thermal burn - isolated to supraglottic
-TX 100% O2
-Edema peaks 48 hours
Upper-airway injury
- Injury below glottis
- composition and amount of inhaled substance
Inhalation injury
- Result of toxic gases & chemicals in inhaled smoke
- Hopoxemia & pulmonary dysfunction
- Respiratory failure
- S/Sx onset unpredictable
- Tx is supportive
- Parenchymal lung injury
Lower airway injury
S/Sx of pain on passive stretching of muscle, decreased sensation, weakness, swelling, pain beyond expectations for the injury.
Compartment syndrome.
Guidelines for escharotomy
1: what pressure
2: doppler pulses
1: pressures greater than 40 mmHg
2: pulses absent in distal arteries
