derm-burns

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  1. Burns
    • injury to body tissues, caused by the following:
    • - thermal
    • - chemical
    • - electrical current- heat
    • - radiation source
    • occur when heat energy is transferred to tissues
    • effects depends on temp of burning agent, duration of contact time and type of affected tissue
    • estimate about 500,000/yr
    • incr survival d/t coordinated national programs, child resistant lighters, nonflammable children clothing- more educated, more protection for children
  2. mechanism injury- thermal
    • exposure contact with flame, scalds/hot liquids, steams or hot objects, most common
    • think about abuse sometimes with kids and elders
    • boiling hot water
  3. mechanism injury- chemical
    • skin contact with caustic chemical compounds such as strong acids, alkali organic compounds
    • think abuse
  4. Electrical
    • what determines the extent of damage incurred with electrical current burns
    • - amt of voltage
    • - length of exposure
    • - type of current and contact
    • - pathway flow and tissue resistance
  5. Mechanism of injury- electrical burn
    • heat generated travels thru body, causing internal tissue damage
    • AC (alternate contact) more dangerous than DC (direct contact)
    • - asso tetanic muscle contration, VFib
    • - this is d/t low voltage so you hold on to it a little bit longer
    • Myoglobin release from tissue may lead to tubular necrosis/ARF
    • - myoglobin release and cause acute renal failure
    • heat goes thru body- only see entrance and exit. there is more damage internally
  6. Mechanism injury- smoke/inhalation
    • smoke/inhalation
    • inhalation of noxious chemicals, hot air from flames causing injury to resp tract
    • common injury: carbonmonoxide poison
    • radiation: least common
  7. Patho of burn
    • Burn-
    • - inc vascular permability
    • - dec intravascular volume- oozing out- blood shift
    • - inc hematocrit- bc plasma leaves
    • - inc viscosity
    • - incr peripheral resistance (burn shock- fluid rescustation)
    • also
    • - inc vascular permability
    • - edema
    • - dec blood volume (dec BP, shifting fluid)
    • - inc peripheral resistance
    • - burn shock
  8. Patho- neuro
    • generally no neuro sequelae unless
    • - associated with trauma
    • - dec perfusion to brain
    • - hypoxia
    • - inhalation injury
    • brain no glucose or oxygen
  9. Patho- cardiovascular/respiration
    • inc HR and PVR
    • dec CO- think inc hematocrit viscosity- fluid resusciatation
    • after 24h, CO returns to normal d/t hydration to meet metabolic needs
    • respiratory:
    • if smoke inhalation injury
    • - edema risk greatest 6-8 h after injury
  10. patho- GU/GI
    • GU:
    • - initial oliguria
    • - w/adequate hydration, ARF may occur- due to myoglobin release
    • GI:
    • - dec mesenteric flow, dec gut motility/absorption- risk of ileus- NG tibe to suction
    • - UGI ischemia- superficial erosions
    • - untreated, leads to ulcers & GIB curling's ulcers)
  11. Patho- immune
    • ** primary defense lost **
    • decreased lymphocyte activity
    • dec immunoglobulin production
    • alterned neutrophil & macrophages functioning
  12. Patho- metabolic
    • increased H2o loss causes surface cooling
    • basic metabolic rate inc to generate more heat & inc temp
    • leads to negative nitrogen balance
    • inc cal and protein
  13. Patho- psychological response
    • 4 stages (Lee)
    • - impact- immediately- shock- disbelief overwhelmed (dont teach)
    • - retreat- depression, denial: F. R monitor, avoid infection
    • - acknowledgement- acceptance, mourning
    • -- support groups helpful
    • reconstructive- limitations accepted , realistic plans made
    •      pt will need to talk about work, kids etc
  14. Patho- burn pain
    • Background pain
    • - at rest or w/minimal movement
    • - continuous, low intensity, may last entire course
    • Procedural pain
    • - r/t therapeutic procedures
    • - acute, high intensity
    • pain meds during peak time work with patient
  15. Patho- inhalation injury
    • trauma to respiratory tissue
    • facial burns, erythema, swelling of oropharynx/nasopharynz, singed nasal hairs, agitation, anxiety, tachyapnea, flaring nostrils, stridor, wheezing, hoarse voice, sooty sputum
    • fiberoptic bronch/lung scan  to confirm
  16. Patho Carbonmonoxide CO poisoning
    • Hbg has 100x more affinity for CO than O2
    • CO binds w/hbg & displaces O2, becoming carbonxyhemoglobin- causes cerebral hypoxemia
    • change is MS, cherry- red color on skin esp mucous membrane
    • check ABG's
    • rx w/100% O2, hyperbaric chamber
  17. Depth of burn- partial thickness
    • superficial (1st degree)- epidermis
    • - erythema pain @ burn site, no blisters
    • deep (2nd degree)- epidermis & dermis
    • - wet, shiny, weepy skin, blisters, severe painful, white- red skin
  18. depth of burn- full thickness
    • 3rd degree- thru SC tissue, blood vessels
    • - deep red, white, black, brown skin, dry, no blanching, insensate to touch
    • 4th degree- thru to bone
    • - color variable, charring in deepest areas, insensate to touch
  19. Extent of burn (size)
    • extent of burn size helps/guides the treatment decisions
    • two commonly charts used to determine TBSA (total body surface area)
    • - Rule of nines chart ** different parts of the body with certain %
    • - lunder-bowder chart- pedi
    • usually, first degree burns/sunburn not inclusive
  20. location of burn
    • head, trunk, neck, chest,- frequent pulmonary complications
    • hands, feets, joints, eyes affects self care
    • ears and nose- inc risk for infection
  21. patient risk factors
    • age- higher mortality in children < 4 adults older than > 65
    • preexisiting medical disorders inc risk complications
    • asso injuries inc risk of complications
  22. management (severity)
    • Minor
    • - ER tx then outpatient
    • - < 15% TBSA if < 40 yrs < 10% if > 40 yo
    • considers burn depth, size, location, victim's age, general health, mechanism of injury
    • place the area in cool water
    • Moderate
    • - hosp for care
    • Mjor
    • - burn specialized unit
  23. Management- Emergent phase
    • starts from onset of burns even until pt is hemodynamically stabilized, collaborative care
    • - first  aid at scene- ABC's
    • - stop/drop/roll
    • - flush chemical burns with water
    • - transport to the hospital
  24. Emergent phase- ABC and Fluid resurcitation FR
    • assess s/s inhalation injury, CO poisoning
    • IV FR- for > 15% TBSA
    • - 2 large + IV thru non burn skin
    • - % of burn calculated & FR initiated
    • - insert urinary catheter
    • - monitor urine output
    • Photos often taken
    • Monitor- BP, HR, urine output
  25. Emergent phase- FR
    • imperative
    • Parkland formula most common
    • Type of FR is determined by
    • - size/depth
    • - age, pre-existing chronic illness (cardiac pt- fluid pay attention)
    • FR with crystalloids (LR) & colloids (albumin)
    • assess response to FR
  26. Emergent phase- wound care
    • strict hand washing with soap and water** infection
    • wear gown and mask during procedure
    • daily shower, wound cleansing
    • change invasive tubing daily
    • maintain sterile technique
    • assess extent/depth of wound
    • monitor CSM/cap refill- eschar
    • escharotomy
    • - initiate abx
  27. Eschar
    • is an area of dead tissue on the skin. the tissue is often necrotic, or created as a result of the early death of otherwise health skin cells such as in burn injury
    • if eschar is noted, escharotomy must be done
  28. echarotomy- indications
    • circulation to distal limb is in danger d/t swelling
    • - slowing capillary refill/pedal pulses
    • - progressive loss of sensation/motion in hand/foot
    • - progressive loss of pulse in the dital extremity by palpation/doppler
    • in circumferential chest burn, pt might not be able to expand chest enough to ventilate and might need escharotomy, the skin in chest
  29. Acute phase wound care
    • cleansing, debridement, shaving, culturing
    • asso of infection/adequate circulation
    • hydrotherapy- immersion, showering, spraying < 30 min
    • debridement- mechanical, enzymatic, surgical
    • topical antimicrobials- silver sulfadiazine, Sulfamylon
    • * may reduce renal buffering and can cause metabolic acidosis
  30. wound care
    • open dsg- antimicrobial cream, OTA
    • closed dsg- gauze impregnated w/antimicrobial applied to wound
  31. wound care 2
    • grafts- dec fluid loss, protection, dec pain, speed healing
    • - temporary- like dsg- biologic, biosynthetic synthetic
    • - autografts- pts own skin grafted
    •   care for donor site as well
    •   immoblized extremity for adherence, elevate x 3-7d
    • cultured epithelial autografts- massive burns
    • - pts skin grown in lab x 20-30d, then applied
    • monitor- s/s, sterile procedure, position pt correctly
  32. Acute phase- nutrition
    • essential- promotes normal healing
    • poor nutrition- negative impact on
    • - immune response
    • - wound healing, metabolic fxn and survival
    • diet, tube feeding, PPN, TPN, alone or combined
    • enc oral route for nutritional replacement
    • assess healing, healing wound, skin tugor
  33. Acute phase- pain management
    • partial thickness & newly harvested skin- very painful
    • full thickness- no pain as no nerve endings
    • IV analgesics ** no SC or no IM- don't know tissue damage inside
    • hypnosis, guided imagery, biofeedback, music therapy
  34. acute phase- psychological support
    • therapeutic listening- support
    • inc self reliance
    • group meetings for pts and families
    • - once at acknowledgment stage
  35. acute phase- physical therapy
    • to maximize functional recovery
    • wound contracture & hypertrophic scarring can become problems
    • therapeutic positioning- generally not comfortable
    • ** no pillows to dec neck contraction**
    • medicate pt before this

Card Set Information

Author:
Prittyrick
ID:
330126
Filename:
derm-burns
Updated:
2017-04-05 03:32:31
Tags:
burns
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Description:
ouch, watch the fire and chemicals
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