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Med-Surg II (Ch. 28)
Problems of Protection
| Question | Answer |
|---|---|
| Sweat and oil glands and their hair follicles | Dermal appendages |
| A thin noncellular protein surface that separates the dermis from the epidermis | Basement membrane |
| The "true Skin" because it is not consistently shed and replaced | Dermis |
| Made up of collagen, fibrous connective tissue, and elastic fibers | Dermis |
| Located within the dermis | blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous glands, and sweat glands |
| Massive fluid loss occurs via this route after a major burn injury and occurs 4x as fast as with intact skin | evaporation |
| The rate of evaporation is in proportion to the _______ burned and depth of injury | Total body surface area (TBSA) |
| This type of burn destroys nerve endings, the ability to activate vitamen D, and sweat glands, reducing excretory ability | Fullthickness burns |
| This type of burn exposes nerve ending, increasing the sensitivity of pain and reduces the activation of vitamen D | partial thickness burns |
| Skin can tolerate temperatures up to ____ without injury | 104F |
| At temperatures of ____ and above, cell destruction is so rapid that even brief exposure damages the skin and tissue below the skin | 158F |
| Describes burns as minor, moderate, or major depending on the depth, extent, and location of injury and describes the criteria for referral to a burn center | The American Burn Association (ABA) |
| Caused by prolonged exposure to low-intensity heat or short exposure to high-intensity heat | superficial thickness wounds |
| Peeling of dead skin | Desquamation |
| Involves the entire epidermis and varying depths of the dermis | Partial-thickness wounds |
| Caused by heat injury to upper third of dermis, leaving a good blood supply | Superficial partial-thickness wounds |
| Wounds extend deeper into the skin dermis, and fewer health cells remain | Deep Partial-thickness wounds |
| Destruction of the entire epidermis and dermis, leaving no true skin cells to repopulate | Full-thickness wounds |
| Dead tissue that must slough off or be removed from the burn wound before healing can occur | Eschar |
| Wound that completely surrounds an extremity or the chest | Circumferential |
| Incisions through the eschar | Eschartomies |
| Incisions through eschar and fascia | Fasciotomies |
| May be waxy white, deep red, yellow, brown, or black | Full-thickness burn wound |
| Causes blister formation; nerve endings are exposed; heals within 10-21 days with no scar; red and moist and blanch with pressure | superficial partial-thickness wounds |
| Blisters do not form; red and dry with white areas of deeper parts; may blanch slowly or not at all; most nerve endings are destroyed; heals within 3-6 weeks with scar formation; skin grafting reduces healing time | Deep partial-thickness wounds |
| Redness with mild edema, pain, and increased sensitivity to heat; heals rapidly within 3-5 days without scar or other complications | Superficial-thickness wounds |
| Wound does not regrow new skin cells; requires grafting; hard, dry, leathery eschar; severe edema usder eschar; heals within weeks to months | Full-thickness wounds |
| Without blood supply | avascular |
| Extend beyond the skin into underlying fascia and tissues | Deep full-thickness wounds |
| Damage muscle, bone, tendons leaving them exposed; occur with flame, electrical, or chemical injuries; blackened and depressed and sensation is completely absent; need early excision and grafting; amputation may be needed | Deep full-thickness wounds |
| When damaged they release chemicals that first cause blood vessel constriction then blood vessel thrombosis which causes necrosis and possibly deeper injuries | Macrophages |
| Occurs after initial vasoconstriction as a result of blood vessels near the burn, dilating and leaking fluid into the interstitial space | Fluid shift |
| a continuous leak of plasma from the vascular space into the interstitial space that causes a loss of proteins and decreased blood volume and blood pressure | Third spacing or capillary leak syndrome |
| Usually occurs within the first 12 hours after the burn and can continue for 24-36 hours | Fluid shift, with excessive weight gain |
| Elevated blood osmolarity, hematocrit, and hemoglobin | Hemoconcentration |
| Starts about 24hrs after injury, when the capillary leak stops and capillary integrity is restored | Fluid remobilization |
| This intervention increases carian output reaching normal levels before plasma volume is restored completely | Fluid Resuscitation |
| Caused by superheated air, steam, toxic fumes, or smoke | Respiratory problems |
| Occurs with burn injuries that result from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns that restrict chest movemetn, and carbon monoxide poisoning | Respiratory Failure |
| Affected when inhaled smoke or irritants cause edema and obstruct the trachea resulting in a reflex closure of vocal cords | Upper airway |
| Acute gastroduodenal ulcer that occurs with the stress of severe injury within 24 hours | Curling's Ulcer |
| Activate the stress response | Catecholamines |
| Peak of increased calorie needs peak between ______ after the burn and can remain elevated for months until all wounds are closed | 4-12 days |
| A central body temp control change occurs to adapt to hypermetabolic state, resulting in development of low-grade fever | "resetting" |
| Causes blood vessels to leak fluid into the interstitial space and white blood cells to release chemicals that trigger local tissue reactions | Inflammatory compensation |
| The first 48 hours | resuscitation/emergent phase |
| The stress response that occurs with any physical or psychological stressors present; most evident is cardiovascular, resp, and GI systems | Sympathetic nervous system compensation |
| Caused by an open flame; occur most often in house fires and explosions; usually results in flash burns | Dry heat injuries |
| Caused by contact with hot liquids or steam | Moist heat (scald) injuries |
| Occur when hot metal, tar, or grease contact the skin, often leading to a full-thickness injury | Contact burns |
| Occur as a result of accidents in homes or industry; severity of injury depends on duration of contact, concentration of chemical, amount of tissue exposed, and action of chemical | Chemical burns |
| Found in oven cleaners, fertilizers, drain cleaners, and heavy industrial cleaners that damage tissues by causing skin and proteins to liquefy | Alkalis |
| Found in bathroom cleaners, rust removers, chemical for swimming pools, and industrial drain clearers that damage tissue by coagulating cells and skin protiens | Acids |
| Found in chemical disinfectants and gasoline and cause damage because they are fat soluble and are easily absorbed through skin producing toxic effects on kidneys and liver | Organic compounds |
| Burns occurring when an electrical current enters the body; "grand masquerader"; high voltage is greater than 1000 volts | Electrical injuries |
| Extent of injury depends on type of current, pathway of flow, local tissue resistance; and duration of contact | Electrical injuries |
| Durationg of electrical contact is increased by this | Tetanic contractions in the forearm |
| Entrace and exit wounds | contact sites |
| Occur when clothes ignite from heat or flames produced by electrical sparks | Thermal burns |
| Occur when electrical current jumps, or "arcs", between body surfaces | External burn injuries |
| Occurs when direct contact is made with an electrical source; internal damage results | True Electrical Injury |
| Occurs when people are exposed to high doses of radioactive material | Radiation Injuries |
| 5th most common cause of unintentional injury deaths in US and 3rd leading cause of fatal home injuries | Fires and burns |
| An estimated ______ fire and burn deaths occur each year | 4000 |
| Factors that increase risk of death r/t burn injuries | age older than 60 years, burn greater than 40% TBSA, and presence of an inhalation injury |
| The fist phase of a burn injury beginning at the onset of injury and continues for about 48 hours | Resuscitation/emergent phase |
| Priority goals of management during the resuscitation/emergent phase | (1) secure airway, 2) support circulatioin by fluid replacement, 3) keep pt comfortable with analgesics, 4) prevent infection, 5) maintain body temp, 6) provide emotional support |
| The patient's preburn weight that is used to calculate fluid rates, energy requirements, and drug doses | Dry weight |
| Used to calculate a burn victim's nutritional requirements | Total body surface area (TBSA) |
| Indication that burn victim may have a pulmonary injury | change in respiratory pattern: progressively hoarse, brassy cough, drool or difficulty swallowing; sounds on exhalation |
| sign of partial obstruction of airway | weezes |
| Causes a "cherry red" color in patients | vasodilating action of carbon monoxide |
| Binds to cell energy-making componenets thereby inhibiting cell metabolism and cell function; produced when plastics or home furnishings are burned | Hydrogen cyanide (toxic by-products) |
| May occur in relation to circulatory overload caused by fluid resuscitation | left-sided congestive heart failure |
| Most common external factor affecting breathing in a burn victim | tight eschar from deep circumferential chest burns |
| Common cause of death in the resuscitation/emergent phase | Hypovolemic shock |
| Indicate electrical damage to the heart | ECG changes |
| Release hemoglobin and potassium when destroyed | RBCs |
| A large oxygen-carrying protein released from damaged muscle and circulates to the kidney | Myoglobin |
| Formed by proteins released by damaged cells that forms a sludge that blocks kidney blood and urine flow and may cause renal failure | uric acid precipitation |
| Fluid resuscitation is provided at the rate needed to maintain hourly urine output at _____ mL or ____ mL/kg/hr | 30-50mL or 0.5 mL/kg/hr |
| The body is divided into areas that are mulitples of 9% to calculate the size of a burn injury in adult pts whose weights are in normal proportion to their heights | Rule of nines |
| The use of vital dyes, indocyanine green (ICG) video angiography,, and laser doppler imaging (LDI) to more precisely measure amount of tissue perfusion of injured tissue | Thermography |
| Reflects fluid shift and direct tissue damage before the start of fluid resuscitation | venous blood analysis |
| If sepsis occurs in a burn patient, the total WBC count may be as low as ______ | 2000 cells/mm3 |
| Laboratory tests that provide useful information about the burn pt's status | urine electrolyte assays, urine cultrus, liver enzyme sudies, and clotting studies |
| Fluid resuscitation formulas recommend that half of the calculated fluid volume for 24hrs be given in the first ___ hours after injury and the other half over teh next ___hours for a total of 24hrs | 8 hours; 16 hours |
| Avoided because they increase capilaary pressure and worsen edema | fluid boluses |
| Adjustment of IV fluid rate on the basis of urine output plus serum electrolyte values | titration of fluid |
| A diurectic given to pt's with electrical burn injuries only after adequate urine output has been established | mannitol (Osmitrol) |
| The surgical procedure for treatment of inadequate tissue perfusion; relieves pressure caused by constricting force of fluid buildup under circumferential burns on extremity or chest and improves circulation; incisions are made along length of extremity | escharotomy |
| A deeper incision extending through the fascia to relieve tissue pressure | fasciotomy |
| Performed to examine vocal cords & airway of patients at risk for obstruction | Bronchoscopy |
| Drugs that may be necessary when a pt's activity during mechanical ventilation severely compromises respiratory mechanics | Paralytic drugs (atracurium or vecuronium) |
| Remove all breathing control from the patient, making mechanical ventilation easier | Paralytic drugs; "bucking" the ventilator |
| Augments the decreased lung volume by providing a continuous positive pressure in airways and aveoli; enhances diffusion of oxygen across alveolar-capillary membrane | positive end-expiratory presure (PEEP) |
| Can be used in pt's receiving mechanical ventilation to reduce oxygen consumption | neuromuscular blocking drugs (atracurium) |
| Begins about 36-48 hours after injury and lasts until wound closure is complete | Acute phase of burn injury |
| __% loss of body weight indicates a mild nutritional deficit | 2% |
| ____% or more loss of body weight indicates a severe nutritional deficit | 10% |
| Determines kilocalories of energy expenditure by measuring oxygen consumption (Vo2)and carbon dioxide production (Vco2) | Indirect calorimetry |
| Begins with wound closure and ends when pt returns to highest possible level of functioning | Rehabilitative phase |
| Removal of eschar and other cellular debris from burn wound | Debridement |
| The application of water for treatment | Hydrotherapy |
| Used to debride soft "cheesy" eschar | washclothes or gauze sponges |
| Can occur naturally by autolysis or artificially by the application of exogenous agents | Enzymatic debridement |
| The disintegration of tissue by the action of the patient's own cellular enzymes | Autolysis |
| A topical enzyme agent used for rapid wound debridement | collagenase (Santyl) |
| Agents applied directly to burn wound in which enzymes digest collagen in necrotic tissue; require moist environment within specific pH range to be active | Topical enzyme agents |
| Mediction used with topical enzyme agents to prevent infection | Polysporin powder |
| Multiple layers of gauze applied over the topical agents on burn wound | Standard wound dressing |
| The number of gauze layers of a standard wound dressing depends on these factors | 1) Depth of injury, 2) amount of drainage expected, 3) area injured, 4) Patient's mobility, 5) Frequency of dressing changes |
| Holds gauze dressings in place and are applied in a specific direction | roller-type gauze bandages or circular net fabrics applied in distal to proximal direction |
| Used for temporary wound coverage and closure; skin or membranes obtained from human tissue or animal donors | Biologic Dressings |
| Used in healing partial-thickness and granulating full-thickness wounds that are clean and free of eschar | Biologic materials |
| Human skin obtained from a cadaver and provided through a skin bank; fresh or frozen | Homografts or allografts |
| Thawed in warm bath of sterile normal saline before application | frozen skin donations |
| Skin obtained from another spcies | Heterografts or xenografts |
| The most common heterograft and is compatible with human skin | Pigskin |
| A form of biologic dressing that adheres to wound and is effective as a dressing until epithelial cell regrowth occurs; requires frequent changes bc it does not develop blood supply and disintegrates in 48hrs | Amniotic membrane |
| Can be grown from a small specimen of epidermal cells from an unburned area of pt's body; cells are regrown in lab to produce cell sheets that can be grafted on pt to generate permanent skin surface | Culture skin |
| A substance that has 2 layers, a Silastic ipdermis and a porous dermis made from beef collagen and shark cartilage | Artificial skin |
| Move into collagen part of artificial skin and creates structure similar to normal dermis | Fibroblasts |
| Artificial dermis slowly dissolves and is replaced with normal blood vessels and this connective tissue | neodermis |
| Combination of biosythetic and synthetic materials | Biosynthetic wound dressings |
| Made up of a nylon fabric that is partially embedded into silicone film. Collagen is incorporated into silicon and nylon. nylon fabric forms adherent bond until epithelialization has occurred. Porous silicone film allows exudates to pass through | Biobrane |
| Made of solid silicone and plastic membranes and are used to cover donor sites | Synthetic dressings |
| Promotes faster healing with low infection rates, minimal pain, and reduces cost; commonly used for care of donor site wounds | Transparent film |
| Reduces time patients are at risk for infection and sepsis | Early grafting |
| Most common treatment for full-thickness and deep partial-thickness wounds | Surgical excision |
| With surgical excision, the patient is taken to OR within ___days of injury | 5 days |
| Surgeon removes very thin layers of necrotic burn surface until bleeding tissue is encountered; bleeding indicates healthy dermis or SQ fat has been reached | Tangential technique |
| Surgeon cuts away burn wound to level of superficial fascia; performed only for very deep and extensive burns | fascial technique |
| Open meshed areas | interstices |
| Pt's own normal flora overgrows and invades other body areas, especially GI tract | autocontamination |
| Organisms from other people or environments are transferred to pt | cross-contamination |
| All burn pt's are at risk for this dangerous infection | Clostridium tetani |
| Reason topical antimicrobial drugs are not applied to freshly grafted areas | They may inhibit cell growth |
| Used when burn pt's have symptoms of an actual infection, including septicemia | Systemic antibiotics |
| used until results of blood cultures and sensitivity status are available | Broad-spectrum antibiotics |
| Used in some burn centers with belief that it reduces cross-contamination | Isolation Therapy |
| Requires all health care personnel to wear gloves during all contact with open wounds | Asepsis |
| Reason plants and flowers, raw foods, rugs and upholstered articles are prohibited | Presents of Pseudomonas and other organisms |
| Gold standard for wound monitoring | Quantitative biopsies of eschar and granulation tissue |
| Infected burn wounds with colony counts of or approaching ___ colonies per gram of tissue may be life threatening | 10 to 5th power colonies |
| Nutritional requirements for pt with large burn area can exceed ______ | 5000kcal/day |
| Nasoduodenal tube feedings are often started within ___ hrs of beginning fluid resuscitation | 4hours |
| Inhibits bone density loss, stregthens muscles, stimulates immune function, promtoes ventilation, and prevents many complications | Ambulation |
| Applied after graft heels to help prevent contractures and tight hypertrophic scars, which can inhibit mobility | Pressure dressings |
| Pressure garments must be worn at least ___hr/day, every day, until scar tissue is mature | 23 hours/day |
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