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Med-Surg II (Ch. 28)

Problems of Protection

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
Created by: 118501829
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