week 12 Flashcards
burn classificiation/assesment
what are the types :
superficial partial thickness (1st )
deep partial thickness burn
superficial partial thickness burn ( 1st degree )
- doesnt need to be hospitalized ( put dressing on to protect that skin )
deep partial thickness burn ( 2nd degree )
- size of a toonie , deep
partial thickness burn - can get away with dressing change to keep to clean - would heal but takes a whiee
but large area - entire hand ( doesn’t happen, bad infection ( will heal but have scar tissues 0
what is full thickness ( 3rd degree )
cut off all the dead tissue ( some type of dressing thing to act like skin )
full thickness burn ( 3rd degree ) smells like burn hair
eschar on it ( black stuff )
not soft and doesn’t feel human and its hard
needs to get grafted ( the photo)
full thickness ( within 48 hours, die from sepsis , ( burn dead skin )
what is this describing ?
full thickness ( 3rd degree ) – cut off all the dead skin ( some type of dressing thing to act like skin )
what is extent – the % tbsa burned ( estimate ) rule of nines
total burning surface area
the higher the total body surface area burn - the more serious it is and the more likely the pt will have roughly recovery and pass away
where is the location that could occur for burns ?
face, neck, chest
hands, feet, joints, eyes
ears
buttocks and perineum
circumferential – limb - perfusion ) chest ( inhalation , movmeent of chest wall )
what do we immediately worry about when they have a burn across their chest / neck/face
worry abt the airway
pulling hot air and they can have burn even in their esophagys
what do we worry abt when they have burn in their hands, feet, joints and eyes
we worry abt how they are able to live ( independence and work )
wr worry abt the contractures and eyes we worry abt the eye sight
why are ears hard to heal ?
alot of cartilgae and not a lot of blood, takes a long time to heal
the classic burn is when thwhat
what are the risk factos for burn
age
med/hx.chronic diseasae, lifestyle other injuries
in class she tlaked abt circumferencial ( expand on it )
the classic burn is when the older person get to a tub and do not realize and lower their backside and now have a burn - worry abt bowel movemnt, getting infection , diarrhea
circumferential - gets all the way around
( chest can epxand require escharotomy )
what undergoes age as a risk factor
organs are not working not as grat and have more diffuclty with rehab
what disease delays healing for burns ?
ms crohns , any type of disease ( diabetes, imapires healing , makes risk goes higher
true or false. sometimes they cut burns tissues, and let it expand ( releases pressure, emerg thing, has to be done )
true
poor kidney function, resp such as copd , huge risk they will die is this true amongst burns
yes this is true
what undergoes lifestyle, alcoholic , not good ability to heal and have liver problems or kidney
is this true
yes this is try
circumferenrail chst burn,,, chest cant expand , and may require what ?
escharotomy ( relieving pressure – there can be chest expansion )
what is the 3 distinct phases that a burn person goes through ?
emerg
acute
rehab
what is the emergency phase
remebeer abcs
resp
– airway
possible injury above glottis
et tube/ventilator
abg, give 02
how ong does a pt passes awya in the emergency phase
48 hours
right when the burns happens watch out fot 24 hours to 48
if they do [ass way usually because airway has closed in and couldnt intubate thwm
what is the first thing you’ll see in an emergency phase ?
usually when they die out of ariway problems its cardioasdcular low blood pressure second adn the first is airway
true or false. think abt airway, think abt injury in the glottis ( look for signs for burning for ae )
anu time of set burning of fac,e shotnnes of breat or whhezing and thinkin abt burnt hair
truew
waht type of asesemtn is important in emerg phase ?
chest assmsnet 0 asucualte an dpositioning
reclal that these are important an dundergoes emerg phase :
recall : remebeer abcs
resp
– airway
possible injury above glottis
et tube/ventilator
abg, give 02
what else ?
– Oropharynx
– Positioning
– DB & C, chest physio, suctioning – CXR, bronchoscopy
* Carbon monoxide (CO) poisoning – EMT treat
what type of position in emerg phase ?
hgih fowlers psoiton
lets ahve a good look isndie the tissue inside the bronchitis an dsee how bad it is how burn it is
why do we do a diagnsotics ?
to get a baseline
if we hear a wheezing what is this indiciating
everyhting is closing down
dont rlly deal with it in the hospital caused because of conbustable material in the air
breathing in their home but not actually getting oxygen connecting to red blood cells
this is what ?
emerg phase carbon monoxide co posiiojign emt trear
what is the treatment for carbon monoxide poisoning - emt trear
skin is cherry red - treatment : is get them outside, and give oxyegn for proabbaly 24 horurs
we have to make sure carbon monoxide is not in their body enough to stop carthe oxygen from getting hemoglobin
Presence of soot on face & mouth – signs of smoke inhalation….no S&S initially, then SOB, wheezing, hoarseness
its giving burnt ( remember the photo ) smoking inhalation
when they got to the hospital:nothing rlly and then suddely sob
upper airway is injured and alot of hot air went in and alot of that tissues to heat
they may look okay but actually not ( listen to talk and breathing )
Partial and full thickness burns, involves face (O2, high Fowlers position)
whole upper body , all the soot
the nurse has a mask on him ( 50 liters going in )
probably need to be intubated ( nurses are close by )
Facial burn involving lips and mouth. L/A fluid given. Edema develops to face & upper airway
*Protect airway *Intubate early p465
Burn to upper airway -hoarsness, stridor, -difficulty swallowing -++secretions
emergency phase: ng care/assessment
what is it ?
abc’s here is the c “ fluid resuscitation “ dr’s area figure out doing a formula
fluid theraphy– need to support BP
what is going on with interstitial spaces?
bp going down and starts hypovolemic and we see this when body surface area is over 15 percent
wha do we see in u/o and elctrolytes for fluid theraphy in emerg phase
low urine outout, we also see low sodium and high potassium
in emerg phase , what is the iv fluid and what is the formula
iv fluid ( parland formula )
— adequacy of fluid replacement, avoid hypovolemic shock
- estbalish 2 large bore ivs or central line ( gieve alot of fluids )
what do have to check in emerg phase?
cicrulation : peripheral pulses, bp, heart rate, the other thign we are checking is urine output ( for perfsion )
urien otput , is telling us if they are getting enough perfusion to their kidneys
true or flase. in emrg phase: capillary seal is lost– so we get a lot of edema , we cannot stop the fluid shifting
true
what is the type of iv fluid do we give patients in emrhg phase?
ringers lactate or normal saline, avoiding hypovolemic shock
true or false. look at the urine output ( between 30 to 50 mls ) perh hour. we also want os sytolic greater than 90 and we want to keep heart rate less than 120
yes this is true
( 3 things we look at )
if these are not good enough then we probably need to revisit and give them more fluid : what are those 3 things
urijne output
heart rate
blood pressure
wound care, analgesia, and immunization is what we look at in emerg phase
yes we look at this too
is this true : wound care is delayed until airway is protected and bp is stable
analgesia - we are giving them stuff ( most time they are in shcok )
9 we give them concisous sedation, fentanyl,versant, mrphone , those type of drugs to help tehm relax
yes
what immunization do we looka t ?
tetanus toxoid
these ppl ar eliekly to have anarobic infection development
we give a tetnaus immunizatin canhelp decrease teh chance
true or flae. during burns
true
When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns caused by a car accident, which of the following findings is of most concern?
a. Urine output of 35 mL/hr
b. Serum K+ of 4.5 mmol/L
c. Decreased bowel sounds
d. BP 86/72 mm Hg
d
what is the acute phase?
phase is so much more stable and each by
when a pt dies in a cute phase, why does this occur
usually from overwhelming infection which then leads to sepsis )
Acute Phase: Ng Care/Assessment
- Pt is more ‘stable’ – ABC are all managed
- Fluid mobilizes and pt is hypervolemic
*Capillary leak sealed so pt will diurese
yes
acute phas/ng care assesment
Goes for multiple ORs for debridement/grafting
* Fluids/nutrition
– Calories, protein – Ulcer protection
* Electrolytes
yes
start tube feed early and grt them eating
electrolytes - sodium , potassium come down
true in acute
what type of calories.protein are we giving pts in acut ephase
exxtra protein pweder ( body needs to repair )
giving them ulcer protection ( h2 blocker ) or ppi - large burn is stressful to the body
edema goes down and sodium and potassium decrease
they are losing extra fluid ( it is coming out.
fluid and nutrition this is where they are hypermetbaollic - burninga. lot of clalroeis
yes
decreasing their iv rate to more normal - no longer than fkuid resesatated
trying to get them back to eating and drinking
yes
Acute Phase: Ng Care/Assessment
pain/symptom management
positioning of pt
pyschologicla care
peds consideration
what undergoes this
pain/symptpm mamagement
-analgesia- can develop tolerance
-anti anxieyy
-pruritis
alot of analegsesi - often times we use
pca’s , catemine infusions when they have the dressing change ( can help decrease the nsrcotic they need )
what is the three common analgesia we use in acute phase
morphine, fentanyl , dilatin( 3 most common )
what should we give right before a dressing change ina cute pjhase
ativan
why is pruritis occuring ina cute phase?
the skin is trying to heal, betadron
positioning of pt of acute phase
this is where we look closely with pt
be careful we are not over stretching the graft – but we also dont wnt them to develop contractures
what undergoes peds considerations for acute phase
encourgae visitiors, and encourgae be able to decrease the akpount of narcotics they need
try to get narcotics when we do not need them for dressing change
hard for little kids- dressings in a prcedure room and look like a concisous sedation
acute phase: ng care/assessment
what do u do?
read the dr’s orders to know the wounds
what are you doing? donor, grafted site, reinforce only, change dressing, what products to use
acute phase : ng care/assesment
basic goals of wound care what undergoes it
cleans/debride it and promote wound healing
looking for signs of infection (infection and healing goes together for graft )
true or false. if it is infected, graft does not want to adhere
true
rehab phase what is it
has all been closed ( heal- done with operations )
fight scaring ( deal with contractures, scaring )
wound care- acute phase
what do we want to prevent
how do we prevent that ?
prevent infection
sterile ns cleaning/debridement
( this isn done in the or ) get massive infection - if not taken off, and general anesthethic ( full thickness burn ) with leatherdy and hardly any blood
what is escharotomy
maintain perfusion, cut ( relieve pressure ) kinda similar to compartment syndrome
what is debridement of burned sin
cheese grater
split thickness skin graft donor site mamagement ( takes a bit of time 2-3weeks to heal )
whats soemthing to consider
- only ting abt donor site ( the redness from where they took the donor site , doesnt usually fade thtat much )
something u can see
wound care- acute phase
hydrotherpahy ( showers, tub )
sterile dressing
-open method
-multiple dressing changes ( OD, BID )
what undergoes open method ( show an example )
open method ( burn in their ear ) often times put ointment in their ear
leave it open to air ( do not put dressing to it )
multiple sterile changing - organizing ur care ( pain killer and visitor is coming, can relax for the rest of the day )
separate room - hydrotherapy
make sure the water is not going to make the person sicker
washing them and putting them on a stretcher and doing dressing change in this room
the pt gets very cold and also have pyxis machine and get narcotics and get supplies
seperate room hydrotherpahy
true
traumatic of dressing changes happens there and goback to their rom
- some hospital uses them and some dont
- depends on the water athe hospital has, not using sterile and tap water
in terms of separate room-hydrotherpahy
this is true
flamazine - silver sulfadiazine cream antimicrobial what is this
silver in it ( good antibiotic ) commonly used and what is does once again is help healing for infection
helps healing and prevent infection
silver ( anticoat ) what activate the silver particles
sterile water activates the silver particles which act upon the wound base to kill a broad spectrum of bacteria
what is this describing : this is expensive but works extremely well depends on how big these wounds are
silver
comes out its like a coat
u need a gown, mask, gloves, and hair cover
this needs to be wet or damp
sterile water and acvate the anticoat to wor and out another dressing on it to keep in intanct : what is this
silver
imagine the picture - covered with a hydrophillic foam dressing after harvesting
donor site: hands off 7 to 14 days , we do not pull it apart - just let it heal
adaptic is what ?
non adhering dressing
commonly used for burns
to get moisture for the area that is healing , the skin is not going to stick to it
skin graft what is our primary goal
to cover the burn wound this is the primary goal
are these tru amongst skin grafts :
fre graft : does not maintain original blood suply. need to care for donor site also
- full thickness ( donor site closed surgically )
-partial/split thickness meshed or unmeshed sheet ( donot site regular drsg changes )
- skin flap - moves skin and sc tissue, maintas original blood supply, vascular attachment is called a pedicle
yes
what are the types of skin grafts
autograft
cea– cultured epithelial autograft
-allograft or homograft
heterograft or xenograft
-biobrane
what is autograft
pts own skin ( this is the most common )
what is cea-cultured epithelial autograft
takes skin and grow it ( they took off their skin and grow it in tge lab 0- very fragile )
what is allograft or homoggraft
another persons skin (this is temp) usually on for three days to 2 weeks
heterograft or xenograft
different species ( temp ) 3 days to 2 weeks
apig or a cow just for covered to buy time
biobrane
temp
most common ( this is product that is bought, manufactured and known as artifical skin nyolon elasticity transparent material )
thin blanket attatch to a machine , airport position ( so we don not get in contractures )
these ppl are typically cold
boot ( make sure when it heals it doesnt heal differently, antt hem to walk, splints to help contractures )
is this true amongst biobrane?
yes this is true
operative debridement of full thickness burns is needed to prepare wound for grafting
yes
blood-maning good perfusion and prepare for good grafting -acut ephase
rehabilitation phase: ng care/assesment
they take 6 months to 2 years to heal
newly grafted skin-remember that it is fragile
true or false. during rehab phase, it is sensitive to touch to sunglight and any type of friction even pressure
yes true
what undergoes rehabilitation phase
wounds healed/grafts adhered
compression garment/dressing
wound care maintenance ( skin , joint )
nutritional care
emotional support
true or false. encourage water bases moisture and protect it from the sunlight
true
what do we have to make sure in rehabilitation phase
make sure they do physio - range of motions and splints
what will start to happen, the skin will anturally go differntly, very early be with splints to make sure ti todsnt happen
contractures so bad they cannot even brush their teeth or hair so make sure to avoid this
get the pts get level of self care
- getting themselves dressed
brushing teeth
lotion etc
( more back into lfie )
a big thing here is push against ( make the scars heal, encourage new skin to heal )
and compression garment and dressing is something these people use
yes this is in rehab phase
true
in terms of nutrional care what happens
go back to normal diet ( apetite is improving, need to have normal levels of calories and protein
in terms of wound care maintenance ( skin/joint ) what do we do?
keeps scars flat , jobst - compression garmenty encourage if not worn might buldge out
wear it 24 horus a day. tak them off when theya re having showering
put them on again
wear 1 to 2 years after their injury
what is hypertrophic scar
this is something we want to avoid , thats why wear those garments
what is a jobst?
compression grament
what is a frostbitem ?
tissue freezng - ice crystals form in tissue and cells
all the way through, it’s just frozen and no perfusion, when a person is in this stafe ( drressing change )
what is superficial or deep ( grade I to IV )
grade III and IV need )_____ and grade II might ?
hospital care
what is monitoring wound-dressing changes
in superficial or deep ( grade I to IV )
dressing changes - on that wound from the freezing, but they will wait, demarcte couple of months once that happen, probably going to amputate
being hospilized for fristbite is
pain
becuase of the wound ( very painful rewarming, these peiple will get narctoics for the pain )
frostbite
for deep- wait to demarcate ( 2 weeks to 5 months ) then debridement and possible amputation
demarcate a time progresses - what ie means divider line injured skin to nromal skin overtime, often time several weeks u will then see a full extent of the damage
true or false. gangrene may evolve after days to weeks after injury
true
frostbite treatment
what to do
handle the area very carefully
these are injured tissues and easily damaged
- soak that extermity to warm water and be very careful , we do not want it too ho )
we do not want person to hit the base ( could damage it more )
- generally warming and good
clothing and jewelry remove from that site ( take it off ) oroabbly going to swell alot
very painful , analgesic ( mrphine and fentanyl ) and the pain these peoplehave can last several weeks to months
frostbite
yes
- What to NOT do? with frostbite
do not squeeze, massage or swueeze the area ( do ot wrap it ins oemting tight )
what is frostbite treatment
- Hyperbaric oxygen therapy (100% oxygen in a controlled setting) – mixed results
- Thrombolytic therapy – needs to be started within 24 hrs of injury, dec need for amputation; risky & may be contraindicated
