Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Hand washing
Assess before Address
Wound assessment – Location, size, color, extent of tissue involvement, cell types
wound base and margins, exudate, condition of surrounding tissue, presence of
foreign bodies
Partial thickness – damage to epidermis, upper layers of dermis, SUPERFICIAL
MINIMAL LOSS OF TISSUE INTEGRITY
Full thickness – damage extends into lower layers of dermis LOSS OF TISSUE
INTERITY
Type of care for open wound – dressings, physical, drug, and nutrition therapies,
electrical stimulation, wound VAC, Hyperbaric oxygen therapy, skin substitutes,
debridement, skin grafting
Burns – type of fluids (LR first, usually within the first hour)
Rule of Nines
Head 9% - 4.5 front, 4.5 back
Right arm 9% - 4.5 front, 4.5 back
Left arm 9% - 4.5 front, 4.5 back
Truck 36% – 18 front, 18 back
Right leg – 18% - 9 front, 9 back
Left leg 18% - 9 front, 9 back
Groin 1%
What to assess? Depth of burn injury – size and depth of injury
severity determined by how much body surface is involved, differences in
skin thickness in various parts of the body
smoke inhalation: cough and hoarseness, chest pain, coughing up blood,
trouble breathing (SOB, noisy breathing) headache, nausea, abd pain,
eye irritation, vision problems, fainting, soot in nostrils and throat
dark nostrils
Treatment: hyperbaric treatment
Superficial thickness – epidermis only (Peeling of dead skin 2-3 days after
Injury
Partial thickness – involves entire epidermis and dermis (varying depths)
Full thickness – destruction of entire dermis and epidermis, skin does not
regrow
Burns from waist up first assessment is ALWAYS THE AIRWAY
What do they sound like? Hoarseness, cough
What type of care – START WITH HAND WASHING AND GLOVES then assess
before address
Lab results in recently burned pt
Hgb – elevated as a result of fluid volume loss
Hct – elevated as a result of fluid volume loss
Urea nitrogen – elevated as a result of fluid volume loss
Glucose – elevated as a result of the stress response and altered uptake
across injured tissues
Sodium – decreased, trapped in edema fluid and lost through plasma leakage
Potassium – elevated as a result of disruption of the sodium-potassium
pump, tissue destruction, and red blood cell hemolysis
Chloride – elevated as a result of fluid volume loss and reabsorption of
chloride in urine
PaO2 – slightly decreased
PaCO2 – slightly increased from respiratory injury
pH – low as a result of metabolic acidosis
Carboxyhemoglobin – elevated as a result of inhalation of smoke and CO2
Shingles – deep pain and itching, followed by vesicles with red base arise along the
nerve line * Treated with antiviral medications
Scabies – intense itching, curved or linear ridges in the skin, visible horizontal white
skin ridges are formed by burrowing of the mite into the outer skin layers
COPD – dusky to cyanotic color, recurrent cough and increased sputum production,
edema, increased respiratory rate, exertional dyspnea, digital clubbing
be careful with oxygen being too high
Sit up and lean forward to assist with breathing
Nasal cannula
Keep 02 sats between 92-94%
Total Laryngectomy
Removal of the larynx, stoma in the neck to breathe
Priorities are airway maintenance and ventilation, hemorrhage
Wound, flap reconstructive tissue care
Pain management
Nutrition
Speech and language rehabilitation
The upper airway is separated from the throat and esophagus and a permanent
Laryngectomy stoma in the neck is created