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Wound Care 4

How many deaths per year are attributed to burns? 3000-5000
What are some careless behaviors that lead to burns? Smoking in bed, MVA, seizures/syncope, Alcohol/drug use, psychiatric conditions
What are the workplace reasons for burns? Chemical, electrical, thermal injures, small equipment fires
What type of injury results from the application of heat, light, or electricity to the skin and disrupting its integrity? Burns! The longer a pt is in contact, the worse the burn - Type and temp of the burning agent will affect extent and degree
What the 5 functions of the skin? maintenance of body temperature; barrier to evaporative water loss; metabolic activity (Vit D production); immunologic protection; protection against environment
What degree of burn involves the epidermis, is cherry red, has mild pain, resolves in 48-72 hrs and heals in 5-10 days? First degree!
What degree of burn has a destroyed epidermal layer, damaged dermis, is wet/painful, has thin walled blisters, is cherry red/pink, BLANCHES WITH PRESSURE and takes 7-10 days to heal? Second degree Superficial partial thickness!
What degree of burn has a totally destroyed epidermis, damaged dermis, THICK walled blisters, is painful and sensitive to pressure, is wet in appearance and may need SKIN GRAFTS? Second degree DEEP partial thickness!
What degree of burn has a destroyed epidermis/dermis, is beefy red, white, khaki or black, has dry/leathery skin, is PAINLESS and will require skin grafts? Third degree full thickness
What degree of burn involves necrosis of the muscle, tendon, and bone, is insensate and requires amputation? Fourth degree
What is a fatal risk if the limb is not amputated after a 4th degree burn? Pt can die of rhabdo
What vital should you track in burn pts? Urine output - Every drop counts
What is useful for estimated scattered burns? Use patient’s hand/fingers as a rough estimate for 1% of total body surface area
What are the 4 types of electrical burn? Current, Arc, Flash and lightning
Which type of current burn has no true entrance/exit wound? A/C current burns - current alternates back and forth from the source to contact points.
Which type of current burn has a definitive entrance/exit? D/C current
What can cause an electrical arc and how hot does it get? Ionization of air particles between two conductors. Heat generated from and arc can reach 4000 degrees C.
What type of burn can result from a power source? Flash burn
What are the chances of this kind of burn and how does the injury occur? Injury results from direct strike or side flash. 1:280,000 chance of being struck
What is the lethal complication from an electrical burn? V-fib or cardiac arrest - V Fib --> Defib!
List other common complications from electrical injury 10-30% show change in EKG or cardiac rhythm; Respiratory Arrest; Retinal detachment; Cataract; Muscle necrosis (rhabdomyolisis); CNS symptoms; C-spine injuries
What do you assess with electrical injuries? Assess for “compartment syndrome”: numbness, tingling, increase pain, decrease or absent pulse with no capillary refill; Frequent vascular checks both proximal & distal to entrance & exit wound; urine color/output; cardiac monitoring
What kind of injury results in facial burns, Singed facial & nasal hair Sooty sputum, Raspy, coarse voice, Tachypnea, Wheezing, stridor. Agitation, anxiety, Dyspnea? Smoke inhalation injury!
How do you assess smoke inhalation injuries? Diagnosis dependent on high suspicion, Pulmonary abnormalities not always present, Smoke inhalation injury can occur in absence of cutaneous burn, Early recognition is the key
What are the smoke inhalation emergent measures? High suspicion=intubate, 100% O2; 100% O2 via tight fitting mask; Baseline vital signs; ABG’s (arterial blood gasses); Baseline CXR; Elevate HOB; Basic burn resuscitation measures; Carboxyhemoglobin level
What are the carboxyhemoglobin levels for carbon monoxide toxicity? < 15% - asymptomatic; 15-20% - flushing, HA; 21-30% - nausea, impaired dexterity; 31-40% - vomit, dizzy, syncope; 41-50% - obtunded, tachypnea, tachycardia; >50% - LOC, coma, death
What are the 5 types of chemical burns? Acid, alkaline, organic compounds, hydrofluoric acid, and tar
What can cause alkaline burns? oven cleaners, drain cleaners, fertilizers, heavy industrial cleaners and cement
How do alkaline burns damage tissues? Liquefaction necrosis and protein denaturation
What can cause an acid burn? hydrochloric acid (bathroom cleaners), oxalic acid (rust removers), muriatic acid (pools)
How do acid damage tissue? coagulation necrosis and protein precipitation which limits depth
What organic compounds can cause a burn? Phenols (disinfectants) and petroleum
How do organic compounds damage tissue? cause tissue damage due to their fat solvent action. Once absorbed they can cause toxic effects on the liver and kidneys
How do hydrofluoric acid burns occur? Etch glass, teflon, clean semicondutors
How do hydrofluoric acid burns damage tissues? Cause immediate pain to area exposed due to tissue necrosis. Can lead to death from HYPOCALCEMIA as the fluoride binds free calcium in the bloodstream
What is the emergent treatment for tar therapy? Cool the burn
What do you do with chemical burns? Immediately flush with copious amounts of water; Powdered chemicals can be brushed from skin; Eye injuries require continuous flush
How do you manage burns? Cleaning and debridement; Topicals; Dressings appropriate for size, type and purpose; Elevation; Kinetic Bed therapy; Splinting and positioning 
How do you assess burns? Extent of burn injury; Depth of burn injury; Signs of infection; Graft viability; Healing progression
What are the various hypermetabolic responses to burns? HTN, tachycardia, fever or mild hyperthermia, weight loss
What should you NOT start with when managing burns? Prophylactic antibiotics - If patient presents late, with cellultitis, Ancef works well
What is the goal of topical antimicrobials? Goal is initially delay wound colonization, later to minimize wound colonization (None will eliminate wound colonization)
What do topical antimicrobials do? provide high concentration of agent to wound surface and penetrates eschar to some extent
What is silver sulfadiazine (SSD) good for? #1 topical agent, activity against a wide range of organisms, painless, poor penetration, leukopenia 5-15%, maculopapular rash <5%, pseudoeschar, take QID or BID, failure (retards wound healing)
What topical agent is creamy, slurry or a solution, has a wide activity against gram positive and gram negative (except staph), is painful, has good penetration and is alternated with SSD? Mafenide Acetate - can be toxic - carbonic anhydrase inhibitor -- resulting in metabolic hyperchloremic acidosis, hyperventilation
What topical agent has no penetration, poor activity and is only for the face? Bacitracin
How much sodium hypochlorite is safe and what does it do? 0.025% safe, higher conc. toxic; Inhibits wound healing – unless buffer added; Broad spectrum activity
What topical agent is an excellent for gram positive (MRSA), is not approved for gram negatives and impairs wound healing? Mupirocin
Which topical agent has the broadest spectrum of coverage (MRSA, VRE, Fungi, Pseudomonas, acinetobactor), and allows x-rays to penetrate and is safe for MRIs? Acticoat/mepilex AG - Use with H2O to activate, must keep moist - Do NOT use saline, leave dressings for 5-7 days - Costly upfront but decreased management costs
Why would a burn pt need higher doses of opioids? High metabolic rate and different pain ratings through the day for each type of burn
What makes burn pts more sensitive to pain? Anxiety and PTSD
What can intensify burn pain over time? Repetitive dressing changes, wound infection, & healing process
What are the parts of burn rehab? Scar management, edema control, stretching, jt mobs, strengthening, functional retraining
Name the rehab treatment for scars ROM, scar massage, compression, early wound healing for prevention of scars
What are the contracture treatments? positioning, stretching, strengthening of ANTAGONIST muscles, splinting, casting, jt mobs
What are the 3 areas to return to function ADLs, transfers and locomotion
What can nutritional support do? Aggressive support counter balances hypermetabolism & protein hypercatabolism associated with burn injury
What are the psychosocial considerations for burn pts? Survival anxiety, searching for meaning, investment of recuperation, acceptance of losses, investment in rehab, reintegration of identity -- both pts and families go through post-burn recovery and rehab stages
What graft is most commonly pigskin, minimizes fluid and protein loss, decreases pain from cutaneous nerve endings, gets trimmed as the wound heals, is inexpensive, has no vessel-to-vessel connection, undergoes avascular necrosis and sloughs off? Xenograft! - Can be easily infected
What is the most commonly used graft that is harvested with a dermatome? Autograft
What type of autograft has better functional and cosmetic results and is used for the face, neck and jts? Sheet
What type of autograft is used to close large burns with limited donor sites, has a higher incidence of scarring and donor skin is passed through a dermamesher to allow stretching of skin to cover area? Meshed
What type of graft has an acellular dermal matrix derived from cadaveric skin and is freeze dried? Alloderm - used as dermal sub for full thickness wounds, fills in tissue defects, minimizes contractures, better cosmetic results, requires 0.006 inches epidermal autograft at time of placement and is difficult to successfully use
What is the name of the graft that is a bilayer skin replacement system with an inner layer matrix of bovine collagen and GAG and an outer layer of silicone? integra - closes wound rapidly, early mobilization, allows for thin autografting 3 weeks later, almost no contractures or hypertrophic scarring, is expensive and not FDA certified
What are the advantages/disadvantages of cultured epidermal autografts? Adv: Patients own epidermis is grown in culture; Used for very large burns;Disadv: Must take 2 full thickness skin Biopsy; Needs 16-21 days to grow; $825/25cm2 - min 15 graft order + $500 fee - $12,875 min charge; Very fragile/thin - No dermis
What are the contraindications to US use for burns? fractures, recently repaired joints or fractures, thrombophlebitis; proximity to pacemaker reproductive organs
What are the parameters that show US decreases wound size? 3MHz pulsed, 3x/wk for 8 wks
What are the effects of Light and conductive heat? Bactericidal effects of UV radiation; Multiple studies have show good bacterial death from UV therapy
What are the effects of e-stim on wounds? Antibacterial effect; In vitro studies; Wound healing effect; Scar tensile strength; Skin collagen; Epithelialization; Capillary density; Protein synthesis; ATP generation
What are 6 approved applications for Hyperbaric Oxygen (HBO)? air/gas embolism, CO poisoning/smoke inhalation, acute/traumatic compartment syndromes or crush, clostridial myonecrosis (gangrene), decompression sickness, problem wounds
What are the other 6 approved HBO applications? Compromised skin grafts/flaps, necrotizing soft tissue infections, refractory osteomyelitis, radiation tissue damage, thermal burns, anemia of acute blood loss
What is the PO2 in arterial blood, soft, tissue and muscles? PO2 in arterial blood is 1500 mmHg and 300 mmHg is soft tissues and muscle; Normal pO2 in arterial blood is 80-100 mmHg
What ATM of HBO? elevated to 2-2.5
Created by: rjchokito



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