Wound Care Exam II Flashcards
1
Q
Standard Care and Tratments
A
- debridement
- cleansing
- dressings
- compression
- antibiotics
- pressure redistribution
2
Q
Cleansing
A
syringe vs. gauze
- saline
- betadine
- hydrogen peroxice
- dakin’s solution
- acetic acid
3
Q
saline
A
normal body fluid
can use on all wounds
especially good for healthy, well healing wounds
4
Q
Betadine
A
- cytotoxic
- for infection and exudate control
- gangrene
- drying effect, good for drainage
5
Q
Hydrogen peroxide
A
- cytotoxic
- use within first 48 hours
- only used for infection or inflammation
6
Q
Dakin’s solution
A
- cytotoxic
- infection and oder
- bleach
7
Q
Acetic Acid
A
- cytotoxic
- infection
- psuedomonas
- vinegar
8
Q
Mild and gentle cleaning if…
A
granulation tissue
9
Q
Aggressive cleaning if…
A
eschar, slough, infection, biofilm
10
Q
Match the dressings to the wound
A
- if it’s wet, absorb it
- if it’s dry, moisten it
- if its a hole, fill it
- if its dirty, clean it
- if its clean, protect it
11
Q
Tissue load management
A
- pressure re-distribution
- move pressure from high risk areas to low risk
- bed based pressure reducing surfaces
- seating surfaces
- off loading gait
12
Q
Foam
A
- usually the first line of defense
- least expensive
- disadvantages include moisture retention and heat retention
- not good for pts who are incontinent or obese
13
Q
Fluid-filled surfaces
A
- high degree of immersion
- air, gel, water
- may retain heat, depending on type of fluid
- better for obese patients
14
Q
Low-air-loss systems
A
- connected, air filled cushions, served by an air pump
- many have automatic adjustment to the pt’s body weight distribution
- immersion is moderate
15
Q
Air-fluidization
A
-micro-fine silicon beads in a box, covered with a loose sheeting material while warmed air is forced through the beads
-beads take on fluid characteristics
-similar to fluidotherapy
-watch for dehydration
-high level of immersion
-GOLD STANDARD for pressure re-distribution
-expensive
“clinitrons”
16
Q
Alternating pressure
A
- air filled chambers with a pump that inflates 1-3-5-7-9 while 2-4-6-8-10 deflate, then reverse cyclically
- changes the bed to body contact points
- not immersion
17
Q
Other tissue load management ideas
A
- no surface takes away from the need for good care and turning every 2 hours
- multiple features available
- W/C fitting can be complex
18
Q
Heel load management
A
- special attention for heels, due to incidence of breakdown
- poorly vascularized
- gold standard is to float the heels
- pillows
- orthotic heel boots
19
Q
Pressure mapping
A
- system used to identify areas of increased pressure or WB
- can be used in any setting
- need patient to act as though they do at home in their environment (ex. let pt ride in wheelchair for a while and get comfortable before assessing, then look at load distribution, then have them show you how they “off load”)
20
Q
Advantages of pressure mapping
A
- individualized and specific
- IDs mild to high risk for pressure ulcers
- locates specific areas at risk for breakdown
- allows for adjustment or ordering of equipment to improve pressure
- educates patients and family about positioning for pressure relief
21
Q
Patients/clients who benefit from pressure mapping
A
- people with hx of skin breakdown or pressure ulcers that have adaptive equipment or seating
- people working with DME company assessing for needs
- anyone with current pressure ulcer
22
Q
Pressure mapping positions
A
- posture
- leaning (sides, forward, back)
- push ups
- glut sets
- reclining and tilting
- equipment adjustments–foot rests, lumbar rolls, air pressure in cushion
23
Q
Appropriate referrals
A
- people who have some sort of seating system and risk factors for skin breakdown or ulcers
- people who qualify for new equipment or seating
- previous people who would benefit from additional education and visual aids
24
Q
Braden scale examines
A
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
25
Braden scale scoring
15-16=mild risk
12-14=moderate risk
less than 12=high risk
26
Skin care education
- bathe daily or every other day with skin inspection
- moisturize daily-no fragrances
- do not rub or massage over bony prominences
- encourage smoking cessation
- positioning/mobility training
- check for moisture and reposition every 2 hours
- clean any incontinece immediately
27
Re-certifation
- every 4 weeks
| - should be re-assessing and revising informally every 2-4 weeks
28
Palliative care
- focus shifts to wound management
- also focus on protection from infection (possibly by use of occlusive dressings or topical antimicrobials)
- odor control
- pain control
- pt and caregiver training
29
Methods of selective debridement
- sharp
- autolytic
- enzymatic
- biologic
30
Methods of non-selective debridement
- mechanical
| - surgical
31
Sharps debridement
- removal of necrotic tissue by use of sharp instruments (forceps, scissors, scalpel)
- selective
- aggressive
- may be painful
32
Sharps debridement not appropriate for...
- pts with insufficient vascular supply or nutrition
| - precuation if on blood thinners
33
Role of debridement (stats)
- important to do it within the 1st 4 weeks
| - if done within 1st 4 weeks, 54% higher wound reduction
34
Termination of sharps debridement
- clinician fatigues
- pain is not adequately controlled for patient
- decline in patient status or tolerance
- extensive bleeding
- new fascial plane identified
- nothing remaining to debride
35
Autolytic debridement
- natural degradation of devitalized tissues with enzymes or moisture
- conservative
- little pain
- slow method
- not appropriate with infection or arterial insufficiency
36
Enzymatic debridement
- use of enzymatic ointments to loosen and remove devitalized tissues and proteins
- papain-urea
- colagenase
- sometimes slow
- nonselective
- may be painful
37
Termination of enzymatic debridement
- once satisfactory debridement has occurred
| - if necrotic tissue fails to decrease in expected amt of time
38
Procedure for enzymatic debridement
- follow manufacturer's guidelines
- physician's prescription
- eschar to be crosshatched prior to application
- moist environment
- observe for S/S of infection
- prophylactic topical antimicrobial therapy prn
39
Biological debridement
"larva therapy"
- sterile-lab raised maggots
- definitely requires a secondary dressing
- very selective
- can help to reduce bacterial counts
- of limited application, partially due to the squeamish factor
40
How biologic debridement works
- larvae release enzymes that degrade/liquefy necrotic tissue
- larvae ingest necrotic tissue and bacteria
- literature supports use for pressure and neuropathic ulcers, traumatic wounds and chronic leg ulcers
41
Mechanical debridement
- use of external forces to non-selectively remove necrotic tissue
- painful
- non-selective
- can cause bleeding and trauma to wound reducing new cells
- wet to dry
- gauze
- whirlpool
- pulsed lavage
42
Surgical debridement
- use of scalpels, scissors, lasers in sterile environment
- performed by physician or podiatrist
- allows for extensive exploration of wounds bed and debridement of deeper structures
43
Indications for surgical debridement
- ascending cellulitis, osteomyelitis, extensive necrotic wounds, undermining
- necrotic tissue near vital organs/structures
44
Contraindications to surgical debridement
-patients who are unlikely to survive procedure or patients with palliative care plans
45
Surgical debridement procedure
- shaving of eschar with dermatome
- incision and drainage (i and D)
- possible tissue biopsy
- followed by appropriate antimicrobial therapy
46
Goals in wound healing debridement
- promote wound cleansing to remove debris and necrosis
- reduce bacterial bioburden and reduce risk of infection
- promote optimal environment for wound healing
- promote inflammation to facilitate angiogenesis
47
Considerations for debridement
- characteristics of wound
- status of patient
- existing practice acts
- clinican's knowledge and skill level
48
Documentation for debridement
- must have specific physician's orders
- selective vs. non-selective
- distinguish conservative sharps debridement
- location, type, and amount of necrotic tissue present
- type and amount of necrotic tissue removed
- instruments used and settings used if applicable
- CPT codes
49
Contraindications for debridement
- dry gangrene
- eschar that is intact, without drainage, erythema or fluctuance on a patient with poor circulation
- unidentified structures in wound bed
50
Steps to prepare patient for debridement
1. assemble equipment
2. Position patient comfortably
3. use proper posture and body mechanics to allow safe techniques and minimize fatigue
4. ensure sufficient lighting
5. wash hands and don gloves
6. remove old bandage and discard
7. discard gloves and put new ones on
8. inspect wound
9. remove gloves
10. explain to pt
11. don gloves and initiate debridement
51
Whirlpool benefits
- cleanses wound
- promotes circulation
- promotes debridement
52
whirlpool precautions
- malignancy in area
- promotes edema
- trauma to healthy tissue
- may promote maceration
- avoid in diabetic wound (because they will macerate)
53
non-thermal temp
better if patient has edema and you are just trying to cleanse the wound
54
Whirlpool precautions/contraindications
Wounds that are-
- clean, macerating, actively bleeding (profuse)
- tunneling, undermining
- arterial insufficient wounds (use low temp)
- >50% clean wound
- moderate-severe edema (venous insufficiency)
- incontinent, confused or combative pt
55
Whirlpool risks
- infection (contaminated water, cross contimination)
- superhydration/maceration
- changing of skin pH
56
Hydrotherapy considerations
Water temp
- non thermal (80-92 F)
- neutral (92-96)
- thermal (96-104)
- patient position (dependency promotes edema)
- duration of treatment
- additives/chemicals
57
Chemical additives
- clinicians must weigh potential benefits of antimicrobial application with known risks of delayed wound healing
- should not be used on chemical wounds
- contraindicated in young, elderly, and those who are sensitive to those agents
- use is not recommended except in isolated patients
58
Hydrotherapy decision making
- positioning
- temp
- time
- agitation
- contamination
- clean up
59
Pulsatile lavage
- promotes localized circulation
- reduces bacterial load
- healthy debridement if using high pressure jet system
- 5-15 psi
- must wear protective clothing
60
Pulsatile lavage with suction
- reliable, focused alternative to whirlpool for wound cleansing
- minimal risk of cross-contamination
- eliminates dependent edema issues
- less time involved for more focused cleansing
- patient specific supplies
- see your PT team member
61
Wound irrigation
- syringe vs. gauze
- should be irrigated on initial exam and with each dressing change
- saline or tap water
- use minimal force
- recommended pressure is 4-15 psi
- may be performed alone or in combo with other modalities
62
Electrotherapy benefits
- increases capillary perfusion
- stimulates fibroblast function
- increases wound tensile strength
- antibacterial effect
- debridement effects
- migration of inflammatory cells
63
Current of injury
- electrical potential across skin
- Na+ ion pump-surface epidermis negative
- current gets messed up with injury
- moisture maintains higher electrical potential
64
Contraindications to e-stim
-basal or squamous carcinoma
-active osteomyelitis
-residue of silver, iodine, or betadine
-pacemaker
-wound over heart region, carotid sinus or larynx
-acute arterial occlusive disease
-local radiation
-DVT or thrombosis
-pregnancy
-metal implants
-a-fib
-ventricular arrythmia
Precuations--osteo
65
Positive polarity
- coagulation of protein
- hardening of tissue
- coagulation of blood
- enhancing congealed scar formation
66
Negative polarity
- liquefying protein
- softening tissue
- bactericidal
- debridement
67
Parameters
- 45-60 mins
- 3-7x/week
- 50-120 pulses per second
- 80-150 volts
68
Reimbursement
- must be performed by PT or physician
| - must document no changes for 30 days
69
Ultrasound
- less research to support
- effective in all phases
- not for use over malignancy, gonads, eyes, over RadRx area, DVT
- see your PT team member
70
US benefits
- stimulates release of chemoattractants by fibroblasts, mast cells, macrophages to reduce inflammation
- may stimulate fibroblast proliferation for collagen deposition, improved gran tissue formation, angiogenesis, wound contraction
- increases wound tensile strength
71
US contraindications
- osteomyelitis
- active bleeding
- severe arterial insufficiency
- acute DVT
- untreated acute wound infection
72
Treatment area
-divided into zones 1/5 times greater than sound head and treated 2-3 mins per zone
73
US debridement
- low frequency US
- cavitation causes destruction of bacteria
- helps with selective dissection and fragmentation of necrosis
- irrigation for cleansing
74
Vacuum assisted closure or negative pressure wound therapy (NPWT)
- negative pressure to wound
- increases perfusion to wound thereby increasing oxygen and nutrients
- helps with drainage control
- change dressing every 48 hours or 3 times/week
75
NPWT
- decreased edema
- increased blood flow
- decreased bacterial numbers
- fluffier granulation tissue and more of it
- promotes epithelialization
76
NPWT indications
- arterial, venous, pressure, mixed, vascular ulcers
- dehisced surgical --wounds with tunneling
- assisting flap survival
77
NPWT not indicated for...
wounds with more than 20% non-viable tissue present
78
NPWT intermittent vs. continuous
- intermittent can further increase the amt and speed of granulation tissue formation
- continuous uniformly applied "pull" can assist the release of intracellular messengers that mediate growth factor production
- usually changed after 48 hrs
- closed system with minimal risk of contamination
79
NPWT Contraindications
- malignancy in wound
- untreated osteomyelities
- non-enteric and unexplored fistulas
- necrotic tissue with eschar
- exposed blood vessels or organs
80
NPWT precautions
- active bleeding
- anticoagulants
- close proximity to blood vessels, organs, bony fragments
- enteric fistulas
81
Anodyne
- photo energy that produces nitric oxide in hemoglobin to re-oxygenate blood and wound bed
- vasodilates blood in the area
- approved for improved superficial circulation and pain management
82
Hyperbaric Oxygen (HBOT)
- full body or multi-place chamber vs. topical therapy
- administering 100% oxygen at a pressure greater than sea level
- daily to BID treatments of 90-120 mins per dive
- promotes angiogenesis and improved oxygen perfusion in blood and plasma hypoxic wounds
83
Benefits of HBOT
- hyperoxygenation
- increasing chamber preasure while breathing increases alveolar po2, blood o2 transport, tissue po2 and healing
- neovascularization
- increased oxygen transport
- requires 10 treatments for angiogenesis to occur
- antibacterial
84
HBOT indications
- diabetic LE wounds (wagner grade 3 or higher not responding to conservative treatment for 30 days)
- compromised skin grafts and flaps
- osteoradionecrosis
- soft tissue radionecrosis
- acute arterial insufficiency
- crush injuries
- necrotizing fasciitis
- gast gangrene
- chronic osteomyelitis
85
Ideal topical treatment/dressing characteristics
- provides a moist wound environment
- provides thermal insulation
- allows removal without causing trauma to wound
- removes drainage and debris
- maintains an environment free of particulates and toxic products
86
TIME principle of wound bed prep
- Tissue non viable or deficient
- Infection or inflammation
- Moisture imbalance
- Epidermal margin
87
Tissue non-viable or deficient (time principle)
Defective matrix and cell debris-->debridement-->restore wound base and ECM proteins
88
Infection or inflammation (time principle)
High bacterial count or prolonged inflammation-->antimicrobials-->low bacterial counts and controlled inflammation
89
Moisture imbalance (time principle)
Dessication or excess fluid-->dressings compressiong-->restore cell migration, maceration avoided
90
Epidermal margin (time principle)
impairment of epidermal migration and ECM-->biological agents, cell therapy-->stimulate keratinocyte migration
91
Primary dressing
comes into direct contact with wound (contact layer)
92
Secondary dressing
placed over primary dressing for increased protection, cushioning, absorption or occlusion
93
Dressing considerations
- anatomical site
- drainage amount
- bacterial load
- periwound integrity
- depth
- edema
- caregiver ability
- aggressive vs. conservative care
- cost and reimbursement
94
Topical treatment strategies
- gauze
- transparent film
- hydrocolloid
- hydrogel
- alginate
- foam
- collagen
- composite
- compression
- combination
- silicone gel sheet
95
Gauze-advantages
- various shapes and sizes
- can be used for packing
- impregnated
- nonadherent
- primary dressing (dry or impregnated)
- secondary dressing (rolls for wrapping, absorbent options)
- can be used for non-selective debridement (mechanical, wet to dry)
96
Gauze-disadvantages
- can be painful with removal
- can harm healthy tissue
- can dessicate wound bed
- little absorption capacity
- no barrier to bacteria
- not cost-effective due to frequent changes
97
Contact layers
- provide wound bed protection with fluid flow-through
- can sometimes be re-used
- usually non-absorptive
- requires secondary dressing
- sometimes impregnated
98
Transparent films
polyurethane film
| clear dressing over IV site, etc.
99
Transparent films-advantages
- wound can be visible
- can stay in place 3-5 days
- promotes autolytic debridement
- semi-occlusive
- protection from friction or shear
- waterproof (good for incontinent patients as a secondary dressing)
- primary or secondary dressing
100
Transparent films-disadvantages
- minimal absorptive capacity (bad for pt with lots of drainage)
- can cause maceration
- can promote skin irritation
- can be traumatic upon removal
- should not be used on infected wounds
101
Hydrocolloid
- "duoderm"
- thick fluid that interacts with wound fluid
- over the counter as "second skin"
102
Hydrocolloid-advantages
- occlusive dressing
- promotes autolytic debridement
- minimal to moderate absorbent capacity
- can be used under compression
- can stay in place 5-7 days
- primary or secondary dressing
103
Hydrocolloid-disadvantages
- can cause wound odor
- risk of hypergranulation
- can macerate periwound
- can cause skin irritation
- can melt down or have edges roll
- should not be used with infected wounds
- not used for wounds with undermining or tunneling (creates an abscess)
104
Hydrogel
- water based gel
- good for arterial ulcers
- can go on almost any wound
- perfect to keep in an OP clinic just in case
105
Hydrogel-advantages
- promotes moist wound environment
- soothes and assists with pain management
- can assist with autolytic debridement
- primary dressing
- can be used for viable and non-viable tissue
106
Hydrogel-disadvantages
- varies in viscosity
- can cause maceration (esp in a draining wound)
- not for heavily draining wounds
- usually require a secondary dressing
107
Alginates and Hydrofibers
seaweed derived dressings
108
Alginates and hydrofibers-advantages
- moderate to heavy draining wounds
- can be used with viable or non-viable tissue
- can reduce frequency of dressing change
- can assist with debridement
- can be used with compression
- can be used with infection
- can be used for packing
- may have hemostatic properties
109
Alginate and hydrofiber-disadvantages
- can dessicate wound
| - can cause alginate scab
110
Foam-advantages
- moderate to heavy draining wounds
- semi-occlusive
- may be adhesive or non-adhesive
- designed for longer wear times
- designed to wick away moisture
- can be used with compression
- protects wound
- insulator
- may retard hypergranulation tissue
- perfect for bony prominences and keeps normal body temp
111
Foam-disadvantages
- can cause maceration
- may dessicate wound bed
- may require secondary dressing
- expensive
112
Collagen-advantages
- moderate to heavy draining wounds
- multiple forms
- works to reduce MMPs which may attract necessary components for healing
113
Collagen-disadvantages
-sensitivities to bovine
114
Composites
- two in one dressing
| - bandaid is a form of a composite
115
Composite-advantages
- multiple features or function in one dressing
- easy to use
- various forms and sizes
116
Combination
-two in one dressing with multiple function.
117
Combination-advantages
- multiple activities available in one dressing
| - provides multiple functions
118
Combination-disadvantages
- may be confusing for caregiver
| - must clarify primary function for reimbursement
119
Silicone gel sheets
- mederma is the over the counter form
- silicone dressing used in the maturation phase
- used by many plastic surgeons
120
Silicone gel sheet-advantages
- assists with scar management
- may reduce or prevent hypertrophic changes and keloid scars
- increases scar mobility and elasticity to reduce contractures
- reduces discoloration of scars
121
Antibiotic ointments
- triple antibiotic ointment
- bacitracin--water based, good for hands and face
- bactroban-effective against MRSA (only one)
- neosporin-watch allergies to neomycin
122
Silvadene
- primary ingredients--sulfa and silver
- watch allergies to sulfa
- can look purulent when ready to remove
- can turn wounds dull or gray in appearance due to silver
- good for burns
123
Silver dressings
- effective against pseudomonus, MRSA, staph, strep, enterococcus
- can stain wound and periwound
- some require activation with sterile water
- some can be rinsed and re-applied
- some are absorbent
- effectiveness varies
124
Hydrofera blue
- bacteriostatic foam-methylene blue and crystal violet
- bacteriostatic against MRSA, VRE, staph, seratia, e-coli, etc.
- requires moisteing with saline or sterile water
- can overlap edges of wound
- requires rehydration--usually daily
- turns light or white on either side when ready to be replaced
- only antimicrobial dressing that can be used in conjunction with enzymatic debriding ointment
- active ingredients are blue and they will transfer into the wound and the dressing will turn white (time to take off)
125
Cadexamer Iodine
-effective against pseudomonus, MRSA, staph, strep, enterococcus
-time release iodine so not cytotoxic but antimicrobial
-for moderate to heavy draining wounds
-can assist with debridement
-looks like rust colored play doh when applied
-looks like yellow applesauce when ready to be removed
-indicated for sloughy, drainage wounds
"ooey-gooey wounds"
-changed every 3 days
-greater than 50% slough with excessive drainage
126
Honey
- medihoney
- promotes a moist wound environment
- highly absorptive
- cleanses and debrides due to its high osmolarity
- helps to lower the wound pH for optimal environment
- non-toxic, natural, safe
- alginate or gel
127
Honey indications
- diabetic foot ulcers
- venous leg ulcers
- arterial leg ulcers
- leg ulcers of mixed etiology
- pressure ulcers
- burns (not full thickness)
- donor sites
- traumatic and surgical wounds
128
Growth factors
-utilize platelet derived growth factor (PDGF) to stimulate proliferative phase of wound healing
129
Oasis
- acellular xenograft made from submucosal lining of small intestine of porcine (applied by physician, only used for diabetic foot ulcers and venous leg ulcers bc medicare covers it for this)
- derived from porcine small intestinal submucosa
- collagenous, extracellular matrix
- temp dressing for partial and full-thickness loss
130
Topical growth factors
- regranex
- part of comprehensive treatment program
- indicated for LE diabetic neuropathic ulcers
- not inexpensive
131
Packing wounds
- fill dead space
- do not 'stuff' the wound
- do not traumatize the wound
- gauze
- foam
- packing strips
- pack with only 1 piece of dressing
132
Skin sealants
- provide additional protection and stickiness to skin for dressing retentions
- pad, spray, lollipop forms
- some are alcohol-free
133
Barrier ointments
- may be petrolatum, dimethicone, zinc oxide
| - used to protect skin from moisture, and possibly friction
134
Adhesives
- variable adhesive properties
- latex-free is available
- some advanced adhesives are safe for fragile skin
135
Peak incidences of burns
- children 1-5 (scalds)
- adolescents (flammable liquids)
- Men 16-40 (burn injury) highest incidence due to occupation and hobbies
136
Burns-devestating injuries
- prolonged and intense pain
- physically and psychologically draining for pt, family, therapist
- psychosocial issues
- crucial to follow up for one year or more
- lower economic status
137
First degree/superficial
- sunburn
- no blisters
- epidermis
- tender to touch
- spontaneous healing 2-3 days no scar
138
First degree/superficial S/S
- dry
- bright red or pink
- blanchable
- no edema (unless on face) or blisters
139
Superficial partial thickness burn
- epidermis and papillary layer of dermis
- intact blisters, bright pink or red inflammation
- will blanch under pressure
- painful and sensitive bc of exposed nerve endings
- heals without surgical intervention in 7-10 days with min scarring
140
Superficial partial thickness S/S
- moist
- weeping
- blistering
- local erythema and edema
- immediate capillary refill
- exposed nerve endings
- wound drainage
- healing within 10-14 days, minimal scarring
141
Taut blister
- natural biological covering
- do not debride or pop
- cover, wrap, and protect
142
Deep partial thickness burn
- epidermis and dermis down to reticular layer
- nerve endings, hair follicles, sweat glands
- mixed red/waxy appearance, may be white
- significant edema with decreased sensation
- heals 3-5 weeks
- STSG usually required
- hypertrophic scarring common
143
STSG
split thickness skin graft
144
Deep partial thickness S/S
- mottled areas with white eschar
- may have ruptured blisters
- sluggish capillary refill
- decreased pinprick
- some pain receptors intact
- healing time 3+ weeks
145
Full thickness Burn
- epidermis and dermis completely destroyed
- subcutaneous tissue may be involved
- covered with eschar (black/deep, red/white)
- STSG necessary, scarring
- peripheral vascular system is damaged and fluid leaks into interstitial space causing edema
146
Full thickness burn S/S
- red, mottled white, gray, black
- necrotic, charred
- leathery, dry, rigid
- exposed deep tissues: tendon or bone or muscle
- insensate
- surgical debridement
- grafting usually required
- these burns are out of your scope, need a plastic surgeon
147
Escharatomy
- same as fasciotomy
- swelling secondary to circumferential burn compromises circulation
- escharatomy must be performed to decrease pressure, restore circulation, save limb
148
Subdermal burn
- even deeper than full thickness
- destruction from dermis through subcutaneous tissue, muscle, bone
- prolonged contact with flame, hot liquid, electricity, exposure to strong chemicals
- charred or mummified appearance
- requires extensive surgery and therapy
149
Subdermal burn S/S
- charred, mummified
- exposed tendons, muscle, fascia
- insensate
- will not heal without intervention
- fasciotomy, escharatomy, grafting
- usually requires amputation
150
conversion of burns
- widening and deepening of the original area of necrosis
| - damage already happened, but didn't show up later
151
Rule of 9's
```
head-9%
anterior torso-18%
post torso-18%
UE-9% each
LE-18% each
genitals-1%
```
152
Thermal burns
```
-direct/indirect contact with flame, liquid, steam
Severity factors:
-contact time
-temp
-type of insult
```
153
Chemical burns
```
-acids, bases, industrial accidents, assaults (pepper spray)
Severity factors:
-alkali burns greater than acid
-contact time
-concentration
-amt of chemical
```
154
Electrical burns
```
-low volt vs high volt
Severity factors:
-AC burn worse than DC
-contact time
-voltage
```
155
Types of burns
- chemical
- electrical
- immersion/scald
- grease
- abrasion
- inhalation
- flash
- steam
- contact
- flame
156
Electrical burn-detailed
- destructive!
- entrance and exit wounds
- cardiac arrhythmias, respiratory distress
157
Inhalation injury
- significantly increases the morbidity and mortality of burns
- may acct for 60-80% of fire related deaths in the US
- associated with prolonged ventilation and bed rest
- absence of smoke detector increases the risk of death in fire 60% of the time
158
Stevens Johnson Syndrome (SJS)/TENS
- immune complex mediated hypersensitivity disorder
- involves skin and mucous membranes
- caused by drugs, viral infections
- TENS is the more severe version where there's more than 30% of TBSA involved
159
Severity of burns
- TBSA burned
- depth of wound
- age of patient
- PMH
- part of body burned
160
Complications of Burn Injuries
- infectoin
- pulm
- metabolic
- heterotrphic ossification
- neuropathy
- scarring
- microstomia and burned eye lids
- amputations
- exposed jts
161
More burn complications
- shock
- CV
- pulm
- hypermetabolism
- thermoregulation
- infection
162
Medical management of a burn
- maintain airway
- determine extent and depth of injury
- prevent fluid loss
- prevent pulm and CV issues
- clean pt and wounds
- place dressings
- surgical management
163
Phases of burn management
- resuscitive
- wound coverage
- reconstructive (this is the phase we will work with the pt in)
164
STSG sheet advantages and disadvantages
Advantage-durable, limits contraction, cosmetic
| Disadvantage-difficult adherence
165
STSG Mesh advantage and disadvantage
Advantage-donor skin covers more of burn, wound bed irregular in shape, wound bed contaminated
Disadvantage-less durable, contracts more
166
STSG Donor Site
- preferred sites (thigh, leg, back, buttock)
- heals by re-epithelization
- heals in 7-14 days
- can be harvested 3-4 times
- treat as partial thickness wound
167
Graft recipient area
- adequately vascularized
- complete contact bw graft and wound bed (wound vac can help with this)
- adequate immobilization
- few bacteria
168
PT Burn Goals
- decrease edema
- prevent contracture (positioning, splinting, ROM)
- maintain/improve strength and activity tolerance
- gait-3 day hold after STSG, but can mobilize with others on day 1
- use ace wraps on LE before gait
- AD are used seldom with burn pts
- minimal activity limitations
- education
- discharge planning
- manage scarring
169
Ace Wraps
Why?
- supports graft or burned area
- promotes circulation
- prevents hemorrhaging
- first phase of scar control
Figure 8 or spiral
Must ace wrap whenever OOB while wound is open
No sleeping in ace wraps
170
LE Burn and Ambulation
- lack of dermal support for BVs
| - pain, edema, venous insufficiency
171
PTs should consider
- prior level of function
- ROM
- strength
- mobility and ambulatory status
- goals for hospitilation
- D/C recommendations
- comorbidities
172
Exercise principles for burns
- deeper burn injury=greater chance of scar contracture
- burn scar tissue is 1/3 less pliable as normal skin
- stretched scar tissue will blanch
173
Precautions for exercise with burns
- PMH
- jt disease
- exposed tendons
- IV lines
- ventilation
174
Contraindications for exercise with burns
- exposed joints
- exposed tendon over
- PIPs
- DVT
- compartment syndrome
175
Graft and exercise
- immobilized 5-14 days
| - can exercise non-grafted areas as long as tension avoided at graft
176
Auto release of scar tissue
- scar may separate with forceful stress, resulting in open wound
- typically not painful
- if small, allowed to heal spontaneously
- if large, may be grafted
177
Contracture body areas
```
Face-microstomia
Neck-flexion
Shoulder-adduction, protraction
Elbow-flexion
Wrist-flexion
Hand-MCP ext, PIP flex, DIP flex or hyperext, thumb add
Hip-flexion
Knee-flexion
Ankle-plantarflexion
Toes-hyperext
```
178
Facial Complications
Ectropion of eye-excessive tear production, conjunctivits, keratitis
Ectropion of mouht-difficulty managing secretions, liquids
179
Shoulder complications
- flexion or adduction contracture
- scapular retraction or protraction
- limited chest wall expansion
180
Wrist complications
- flexion or ext contracture
| - inability to ulnarly deviate
181
Z-plasty
scar band has formed in axilla
| zplasty releases contracture
182
Scar management
- every burn will scar
- we cannot prevent scarring but we can potentially change the function of the scar
- 80% of burn pts will develop hypertrophic scarring--use of compression indicated in most burns
- scar will mature over course of teh year
- massage
183
Compression therapy-why it works
- mechanical thinning effect
- decreases blood flow to area
- reorganizes collagen bundles
- decreases tissue water content
