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Skin Protective Barrier Against Injury & Infection

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Skin Protective barrier against injury and infection:

  • Thermoregulatory control
  • Regulation of fluid loss
  • When damaged, hypothermia, increased fluid loss, infection, and compromised immunity can result

Size Percentage of total burn surface area (TBSA)

  • Estimate using rule of nines- differs for pediatric and adult patients
  • Types

    • Thermal- results from contact with hot substances such as flame, hot liquids, steam, and hot solid objects.

    The longer the contact, the deeper the wound. Oil based liquids with higher boiling points cause deeper burns than water based liquids. Chemical- caused by strong acids, alkalis, and organic compounds. Can continue to cause damage for up to 72 hours unless properly neutralized. Electrical- THINK CARDIAC! Can lead to arrhythmias, vfib, or paralysis of the respiratory muscles. Will generally only see entry and exit wound, but extensive damage could be present internally.

    Radiation – caused by exposure from sunlight, tanning booths, x-rays, or nuclear emissions. Smoke and inhalation- can occur concurrently with chemical and thermal burns. Signs include facial burns, hoarseness, soot in nose or mouth, carbon in the sputum, lip edema, and singed eyebrows or nasal hair. Patient would need respiratory interventions such as bronchoscopy, intubation, and gas monitoring. Frostbite – caused by exposure to very cold temperatures. Blood flow to area is reduced and the skin freezes and begins to die leading to necrosis, gangrene, hypothermia, and possibly cardiac arrest.

    Systems Affected. Respiratory – direct airway or inhalation injury, carbon monoxide poisoning, smoke inhalation, alveolar damage, pulmonary edema, and decreased oxygen diffusion. Cardiovascular – fluid volume deficit, decreased MAP, decreased cardiac output, hypovolemic shock, decreased myocardial contractility, vfib, and cardiac arrest. Renal – decreased renal perfusion and oliguria that can lead to AKI. Monitor UOP closely and observe urine color. Gastrointestinal – ileus, stress ulcer formation, intra-abdominal hypertension and compartment syndrome can damage the gut, kidneys, and liver. Endocrine- increased metabolic rate, increased caloric needs, increased cortisol levels may cause insulin resistance and hyperglycemia. Immune – immunosuppression·Musculoskeletal – contractures and mobility is compromised during the healing process

    Management Airway – ensure patient has a patent airway. Breathing- assess respiratory rate and depth, listen to breath sounds, pulse ox Circulation – assess presence, rate, and rhythm of pulses. Check cap refill, skin color, and temp. Obtain vitals, establish IV access, elevate extremities, manage pain, GCS. 20% TBSA generally goes to ICU for aggressive fluid resuscitation and airway management. Once eating again high protein, high calorie diet

    Stages. Emergent – resuscitative. Acute- wound healing· Rehabilitative- restorativeFluid resuscitation·Start fluids to prevent hypovolemic shock- usually isotonic (LR). Foley to accurately measure UOP (if patient is unconscious or incontinent), otherwise void to urinal, speci hat, or condom cath· Monitor renal labs, mental status, vitals, hourly UOP, hemodynamic statusLayers and Degrees. Epidermis- protective barrier, holding in fluids and electrolytes, thermoregulation. Dermis- tissues with blood vessels, hair follicles, nerve endings, and sweat glands. Subcutaneous tissue- major vessel networks, nerves, fat, lymphatics. Acts as a heat insulator to muscles and internal organs. Superficial burns (first degree) – damage only the epidermis. Cause erythema, skin blanching, mild pain and swelling. Partial thickness (second degree) – damage to the epidermis and part of the dermis.

    Symptoms include blisters, edema, pain, and sensitivity to cold air. Full thickness (third/fourth degree) – extend to the subcutaneous tissue so the skin can’t heal on its own. Vessel will be visible and muscles, tendons, and bones may be damaged. Symptoms are no pain, hematuria, and possible shock. Skin grafting is usually required. Function loss of extremities and joints, and possible amputation. Dressings. Dressings done by BDT, unless comes loose, then RN can change the outer layers. Silver impregnated dressings- Mepilex Ag, silvadene, miliken (?)- To help prevent infx. Typically wrapped with kerlix and ace Poly/cuti/kerlix/wrap Face care- warm moistened gauze to wipe away top layer, generously apply poly. Xeno vs autograft- determined once in OR, could have wv placementPT/OT ROM- within 24 hours after surgery. Splints- extremity, airplane, or neck. Mobility and ADLs. Skin inspection. Burn on back or buttocks- minimize supine position, encourage side lying or prone

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