NPTE
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| Layers of superficial burn | epidermis only
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| Appearance of superficial burn | red, dry tender
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| Healing of superficial burn | 2-3 days, no scars
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| superficial partial thickness layers | epidermis into papillary layer of dermis
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| superficial partial thickness appearance | blisters intact, red
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| superficial partial thickness healing | 7-21 days w/ minimal scarring
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| Deep partial thickness layers | epidermis, dermis (including hair, sweat glands)
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| Deep partial thickness appearance | Marked edema, mixed red w/ waxy white, broken blisters,
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| Deep partial thickness healing | spontaneous, 3-5 wks excessive scarring
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| Full thickness layers | epidermis, dermis, subcutaneous, possible into muscle
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| full thickness appearance | white, gray, black, escar, leathery
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| full thickness healing | heals w/ graft
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| subdermal layers | all into muscle and bone
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| subdermal appearance | charred
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| subdermal healing | grafting, tissue defects
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| hand position to prevent deformities after burn | wrist ext, MCP flex, PIP and DIP ext, thumb abd
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| hip position to prevent deformities after burn | neutral roation w/ slight abd
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| redness w/ lesions, itchy, weeping crusted skin | dermatitis
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| inflamation, pus filled vessicles, itching | Impetigo
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| pus, hot, red edematous, fever common | cellulitis
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| contraindications of shingles | US, heat
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| erythematous plaques covered w/ silvery scale | psoriasis
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| red rash w/ raised scaly plaques | lupus
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| skin is taut, firm, edematous, firmly bound | scleroderma
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| scleroderma precaution | sensitive to pressure, acute HTN can occur
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| round, irregular, dry, flat on sun exposed skin | actinic keratosis (pre-cancerous)
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| raised lesion on trunk usu in elders | seborrheic keratosis
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| ivory raised w/ indented center in fair skinned | basal cell (malignant, rarely mets)
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| poorly defined borders, red, flat, sun exposed skin | squamous cell (can met)
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| asymmetric irregular border, color variation | malignant (from melanocytes)
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| red or purple/blue, usu. LE | kaposi's sarcoma
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| Transparent film indications | autolytic debridement, secondary dressing, Stage I and II,
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| transparent film considerations | avoid w/ infection, non-absorptive
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| hydrocolloids indications | mild exudate, maintains moist, supports autolytic
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| hydrocolloids considerations | odor w/ yellow exudate is normal when dressing is removed avoid in infections or with heavy exudate
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| hydrogel indications | necrosis, burns, rehydrates, autolytic
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| hydrogel considerations | comes in many types and absorptive capacity varies, don't use sheet w/ infection dressing must be changed every 8-48 hours
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| Foams indications | min-mod exudate
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| Foams considerations | do not use w/ dry escar or wounds w/ no exudate
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| Alginates indications | mod to large amount of exudate infected and non-infected
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| Alginates considerations | car dry wound bed
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| Gauze dressing indications | mechanical debridement, infected wounds, several types
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| Autolytic type and contraindications | (Natural) infection, immunosuppressed, dry gangrene, dry ischemic
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| Enzymatic type and contraindications | (enzyme to necrotic tissue) ischemia, dry gangrene, clean granulated wounds
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| Mechanical type and contraindications | (nonselective) clean granulated
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| Sharp type and contraindications | (selective w/o anesthesia) clean, advanced cellulitis w/ sepsis, infection threatens life, pt on anticoagulants
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| Surgical type and contraindications | (non-selective, wide excision) cardio-pulm disease, DM, severe spasticity, pt cant tolerate, short life expectancy, QOL won't be improved.
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