Ulcers and Burns Flashcards
Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to
underlying tissue
Pressure ulcers
How long can superficial tissue tolerate pressure?
2-8 hours
How long can deep muscles, connective, and fat tissues tolerate ischemia?
2 hours
Epidermis, non-blanching erythema
Stage 1
epidermis/dermis; shallow opening; blisters
Stage 2
Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia
Stage 3
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendons, joint capsule).
Stage 4
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
Unstageable
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration,
or epidermal separation revealing a dark wound bed or blood-filled blister.
Deep Tissue Pressure Injury
Medical devices–related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes.
Medical Device-Related Pressure Injury
Most common site of pressure ulcer
Ischium (28%)
2nd most common site of pressure ulcer
Sacrum (17-27%)
Common site of pressure ulcer in a w/c bound patient
Ischial tuberosities and feet
Least common site of pressure ulcer
Heel (9-18%)
Common site of pressure ulcer in children aged 10 wks - 13 y/o
Occiput
Common site of pressure ulcer in patients with Acute SCI
Sacrum and Heels
An ulcer caused by venous insufficiency
Venous ulcer
Where can venous ulcer be found?
Medial malleolus
S/Sx of Diabetic Ulcer
Loss of sensation
Tingling sensation
Complete or partial arterial blockage may lead to tissue necrosis and or ulceration
Arterial wounds
S/Sx of Arterial Wounds
Pulselessness of the extremity
Painful ulceration
Delayed capillary return
Cold skin
Where can arterial wounds be found?
Lateral malleolus
Tissue damage and cell death caused by intense heat, electricity, ultraviolet radiation (sunburn) or certain
chemicals (such as acids), which denature proteins and cause cell death in the affected areas
Burns
Causes of burns
Thermal
Chemical
Electrical
Radiation
Most central area of the burn and has the most contact with the heat source. Cells in this zone are irreversibly/permanently damaged.
Zone of Coagulation
How can the Zone of Coagulation be healed?
Skin grafts
This zone has a decreased blood flow. Damage in this area is still reversible and responds to resucitation.
Zone of Stasis
In this area, cells have sustained the least damage and should recover within 10 days. It recovers spontaneously with no lasting effects
Zone of Hyperemia
Erythematous, pink or red; irritated dermis with no blisters
Epidermal burns
erythematous with blanching and brisk capillary refill with intact blisters, moist weeping, or glistening surface when blisters are removed. Bright pink or red in color
Superficial partial-thickness burn
Mixed red, waxy white; blanching with slow capillary refill. Presents with broken blisters, wet surface; sensitive to pressure but insensitive to light touch soft pin prick.
Deep partial-thickness burn
Parchment-like, leathery, rigid, and dry in appearance. White (ischemic), charred, tan, fawn, or black in color
Full-thickness burn
There is evident subcutaneous tissue and muscle damage. It also presents with neurological involvement
Subdermal
Three widely accepted means of determining the extent of body surface area involved.
Palmar method
Rule of Nines
Lund and Browder
How much does the head make up in adults in the Rule of Nines?
4.5%
How much does the whole anterior torse make up for in the rule of nines?
18%
How much does an anterior leg make up for in the rule of nines?
9%
How much does an anterior arm make up for in the rule of nines?
4.5%
How much does an anterior leg make up for in the rule of nines (children)?
6.5%
How much does the head make up for in the Rule of Nines (children)?
8.5%
Minor burn criteria
< 10% TBSA burn in adult
< 5% TBSA burn in younger or older pts
< 2% full-thickness burn
Moderate burn criteria
10-20% TBSA burn in adult
5-10% TBSA burn in younger or older pts
2-5% full-thickness burn
High-voltage burn
Circumferential burn
Suspected Inhalation injury
Medical problem
Major burn criteria
> 20% TBSA burn in adult
10% TBSA burn in younger or older patient
5% full-thickness burn
Other criteria same with moderate
Significant burns to face
Complication of burn injury
Infection
Shock
Pulmo complications
Metabolic complications
Cardiac and circulatory complications
Integumentary scars and contractures
a tissue transferred from one part of the body to another
Autograft
tissue transferred from a genetically different
individual of the same species.
Homografts/Allografts
a graft transferred from an individual of one species to an individual of another species
Xenografts
Manufactured products that work as skin equivalents
Biosynthetic grafts
Includes epidermis and dermis. The incision is made up to the subcutaneous tissue
and a wedge of skin is obtained.
Full-thickness graft
Surgical in the form of the letter “z” used to lengthen a burn scar; For aesthetics and cosmetics
Z-plasty
