Med Surg 265 - Exam 3 ALL ANSWERS 100% CORRECT
SPRING FALL-2022 LATEST SOLUTION GUARANTEED
GRADE A+
- Tissue destruction caused by a burn injury leads to local and systemic problems that affect Fluid and electrolyte balance leading to:
o protein losses, sepsis, and changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning
- The extant of problems is related to:
o age, general health, extent of injury, depth of injury, and the specific body area injured
- Late complications may occur after healing:
o Contracture formation and scaring
- The priorities of care are the prevention of infection and closure of the burn wound
- Delay in wound healing is a key factor for all systemic problems and major cause of disability and death among patients who are burned
Skin changes
- Largest organ of the body
- Has two major layers:
o Epidermis
▪ Outer layer of skin
▪ Can grow back after a burn injury
▪ No blood vessels
▪ Nutrients is diffused from the dermis
o Dermis
▪ Thicker than the epidermis
▪ Blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous glands and sweat glands
- When burn injury occurs, skin can re-grow if parts of the dermis are present
- When entire dermal is layer is burned, cells and dermal appendages are destroyed, and the skin cannot restore itself
o Dermal appendages
▪ sweat glands, oil glands, and hair follicles
- Sub Q tissue is below the dermis separated by the basement membrane
- Deep burns sub Q tissue can be damaged leaving bone, tendons and muscles exposed
Functional Changes
- Burns break the barrier, increasing risk for infection
- After a burn, massive fluid loss occurs through excessive evaporation
- Full thickness burns destroy sweat glands, reducing excretory ability
- All burn injuries are painful
- partial thickness burns; nerve endings are exposed, increasing sensitivity and pain.
- Full thickness burns nerve endings are destroyed
o At first these burns may only have pain on wound edges
o Often patients have dull/pressure type pain here
- Partial thickness burns reduce the activation of vitamin D,
- Full thickness burns activation of vitamin D is lost completely
- Body temp regulation is compromised
o Range 84.2-109.4
o Temp rises rapidly under the dermis once heat is applied to skin
o Decrease in temperature when heat is removed from skin
- A patient who receives a burn often experiences reduced self-image
Depth of Burn Injury
- The severity of a burn is determined:
o how much of the body surface area is involved
o the depth of the burn
- The degree of tissue integrity loss
o agent causing the burn
o temp of the heat source
o how long the skin is exposed
, Classification of burn depth (BOX)
Superficial - Sunburn, flash burn
-Pink to red - Mild edema
-Pain - No blister
-No eschar - Healing in 3-6 days
Superficial- thickness wounds
-No skin graft needed
o Least damage - Only epidermis is damaged
o Caused by prolonged exposure to low intensity heat (sunburn, flash exposure to high intensity heat)
o Redness with mild edema, alterations in comfort and increased sensitivity to heat occurs as a result.
o DESQUAMATION (peeling of dead skin) 2-3 days after the burn. Heals rapidly 3-6 days
Classification of burn depth (BOX)
Superficial partial thickness wounds Superficial partial thickness - Scalds,
flames, brief contact hot objects
o Damage to upper third of the dermis, leaving a good blood supply
o Pink, moist, and BLANCH (lighten when pressure applied), and blisters form
-Pint to red -Mild to moderate edema
o Increase pain sensation (intense)
-Pain -Blister
o Heals in 10-21 days with no scar with minor pigment changes
-No eschar -Healing in 2 weeks
-No skin grafts
Deep partial thickness wounds
o Damage is deeper into the dermis Classification of burn depth (BOX)
o Blisters generally do not form Deep partial thickness - Scalds, grease and
o Wound surface is red, dry, with white areas in deeper parts, chemicals
o When pressure is applied it blanches slowly or not at all
o Edema moderate, less pain than superficial wounds because more nerve endings are destroy ed-Red to white -Moderate edema
o Blood flow is reduced -Pain -Blisters are rare
o Hypoxia and ischemia can occur -Soft and dry eschar -Healing in 2-6 wks
o Hydration, nutrition and O2 is needed for regrowth -Graft can be used for prolonged healing
o Can convert to full thickness wounds due to infection, hypoxia and ischemia
o Heal in 2-6 weeks with scar formation
o May need skin graft
Classification of burn depth
(BOX)
Full-thickness wounds Full thickness - Scalds; tar,
grease, chemical and
o Destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. electricity
o This skin does not regrow, closes by wound contraction and skin grafting.
o Hard-dry ESCHAR that forms -Black, brown, yellow, white
o THE ESCHAR IS DEAD TISSUE AND MUST SLOUGH OFF OR BE REMOVED FOR HEALING TO OCCUR and red
o Edema is severe under the eschar in a full thickness wound
-Severe edema
Blood flow and chest movement for breathing may be compromised by tight eschar
-Yes and no pain
o Escharotomies (incisions through the eschar)
-No blisters
o Fasciotomies (incisions through the eschar and fascia)
-Hard and inelastic eschar
o May be needed to relieve pressure and allow normal blood flow and breathing
-Healing weeks-months
o Waxy white, deep red, yellow, brown or black
-Skin graft is needed
o Sensation is reduced or absent
o Healing time depends on establishing a good blood supply
o Weeks to months
Deep Full-Thickness Wounds
Classification of burn depth (BOX) Deep
o Extend beyond the skin, damaging muscle, bone, and tendons
full thickness - Flames; electricity, grease,
o Appears blackened and depressed and sensation is completely absent
tar, chemicals
o All full thickness burns need early excision and grafting
-Black -No edema
o Grafting decreases pain and length of recovery
-No pain -No blister
o Amputation may be needed when an extremity is involved
-Hard and inelastic eschar
-Healing weeks-months
-Skin graft is needed
, Class of burns and criteria (BOX)
Minor burns
-Partial <10% TBSA
-Full <2% TBSA
-Younger than 60 years old
Moderate burns
-Partial 15-25% TBSA
-Full 2-10% TBSA
-Younger than 60 years old
Major burns
-Partial >25% TBSA
-Full >10% TBSA
-Involving eyes, ears, face, hands, feet,
perineum
-Electrical injury
-Older than 60 years old
-Other chronic metabolic disorders
Vascular changes
- Fluid shift
o blood vessels near burn dilate and leak fluid into interstitial space.
- Third spacing or capillary leak syndrome TACHY AND HYPOTEN
o continuous leak of plasma from vascular space to interstitial space
- The impaired FLUID AND ELECTROLYTE leads to decreased blood volume and decreased BP
o Edema occurs throughout the body
o Excessive weight gain occurs in the first 12 hours after the burn
▪ Can continue for 24-36 hours
- Profound disruptions of FLUID AND ELECTROLYTE balance and acid-base balance often include
o hypovolemia, metabolic acidosis, hyperkalemia, and hyponatremia
o Hyperkalemia
▪ Direct cell injury releasing large amounts of potassium
o Hyponatremia
▪ Retained sodium in the interstitial space due to stress (RAAS)
▪ Aldosterone increases increasing sodium reabsorption by kidneys
- Hemoconcentration (elevated blood osmolarity, hematocrit, and hemoglobin) develop from vascular dehydration.
- FLUID REMOBILIZATION starts roughly 24 hours after injury
, o capillary leak stops
- Diuretic stage begins at about 48-72 hours after the fluid shifts back into the intravascular space
o Blood volume increases in the kidney
o Diuresis occurs unless kidneys are damaged
o Body weight becomes normal over the next few days as edema subsides
o Hyponatremia and hypokalemia
o Anemia occurs due to hemodilution
▪ Not severe enough for blood transfusion
▪ Transfusions are needed if hematocrit is < 20-25% with s/s of hypoxia
o Protein continues to be lost from the wounds
o Metabolic acidosis is possible due to the loss of bicarb in the urine and increase rate of metabolism
Cardiac changes
- Heart rate increases resp and glucose increase
- Cardiac output decreases
o Due to hypovolemia
o May remain low until 18-36 hours after injury
o Improves with fluid resuscitation
- Fluid replacement and oxygen prevent further complications
Pulmonary Changes
- Direct injury to the lungs from flames rarely occur
- Most problems caused by:
o superheated air, steam, toxic fumes, or smoke
- Such problems are a major cause of death in patients with burns and occur mostly when the burn takes place indoors
- Injuries from burns that cause RF:
o Airway edema, pulmonary capillary leak, chest burns and CO2 poisoning
- Respiratory damage can occur in the upper and major airways and the lung tissue
o Upper airway affected
▪ Inhale of smoke causing edema of the mouth and throat causing airway obstruction
- Smoke and gas slow the ciliated membranes lining the trachea down allowing particles to enter the bronchi
o Lining may slough 48-72 hours after injury and obstruct the lower airway
- Lung tissue damage results from toxic irritant
o Damage to the alveoli and capillaries
o Leaky capillaries can cause alveolar edema
▪ Can occur immediately or up to a week of the injury
o Fluid that diffuses into the lung tissue spaces contain proteins forming fibrinous membranes
▪ leading to respiratory distress
o Progressive pulmonary failure develops
▪ leading to pulmonary insufficiency and infection
Gastrointestinal Changes
- Blood flow is decreased due to decreased cardiac output
- TISSUE INTEGRITY AND MOTILITY are impaired
- Sympathetic system release
o Epi and norepinephrine
▪ Decreasing GI mobility and reduce blood flow to the area
▪ Peristalsis decreases
• Paralytic ileus may develop
▪ Secretions and gasses collect in the GI tract
• Causing abdominal distention
- Curling’s Ulcer (acute gastroduodenal ulcer that occurs with the stress of severe injury) may develop within 24 hours after the burn
injury due to:
o Reduced GI blood flow and mucosal damage
▪ Decreased gastric mucus production and increased hydrogen ions
• Ulcers may develop
o Less common due to medication treatments
▪ H2 histamine blockers, PPI, and enteral feeding
Metabolic Changes
- Injury greatly increases metabolism (hypermetabolism)
SPRING FALL-2022 LATEST SOLUTION GUARANTEED
GRADE A+
- Tissue destruction caused by a burn injury leads to local and systemic problems that affect Fluid and electrolyte balance leading to:
o protein losses, sepsis, and changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning
- The extant of problems is related to:
o age, general health, extent of injury, depth of injury, and the specific body area injured
- Late complications may occur after healing:
o Contracture formation and scaring
- The priorities of care are the prevention of infection and closure of the burn wound
- Delay in wound healing is a key factor for all systemic problems and major cause of disability and death among patients who are burned
Skin changes
- Largest organ of the body
- Has two major layers:
o Epidermis
▪ Outer layer of skin
▪ Can grow back after a burn injury
▪ No blood vessels
▪ Nutrients is diffused from the dermis
o Dermis
▪ Thicker than the epidermis
▪ Blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous glands and sweat glands
- When burn injury occurs, skin can re-grow if parts of the dermis are present
- When entire dermal is layer is burned, cells and dermal appendages are destroyed, and the skin cannot restore itself
o Dermal appendages
▪ sweat glands, oil glands, and hair follicles
- Sub Q tissue is below the dermis separated by the basement membrane
- Deep burns sub Q tissue can be damaged leaving bone, tendons and muscles exposed
Functional Changes
- Burns break the barrier, increasing risk for infection
- After a burn, massive fluid loss occurs through excessive evaporation
- Full thickness burns destroy sweat glands, reducing excretory ability
- All burn injuries are painful
- partial thickness burns; nerve endings are exposed, increasing sensitivity and pain.
- Full thickness burns nerve endings are destroyed
o At first these burns may only have pain on wound edges
o Often patients have dull/pressure type pain here
- Partial thickness burns reduce the activation of vitamin D,
- Full thickness burns activation of vitamin D is lost completely
- Body temp regulation is compromised
o Range 84.2-109.4
o Temp rises rapidly under the dermis once heat is applied to skin
o Decrease in temperature when heat is removed from skin
- A patient who receives a burn often experiences reduced self-image
Depth of Burn Injury
- The severity of a burn is determined:
o how much of the body surface area is involved
o the depth of the burn
- The degree of tissue integrity loss
o agent causing the burn
o temp of the heat source
o how long the skin is exposed
, Classification of burn depth (BOX)
Superficial - Sunburn, flash burn
-Pink to red - Mild edema
-Pain - No blister
-No eschar - Healing in 3-6 days
Superficial- thickness wounds
-No skin graft needed
o Least damage - Only epidermis is damaged
o Caused by prolonged exposure to low intensity heat (sunburn, flash exposure to high intensity heat)
o Redness with mild edema, alterations in comfort and increased sensitivity to heat occurs as a result.
o DESQUAMATION (peeling of dead skin) 2-3 days after the burn. Heals rapidly 3-6 days
Classification of burn depth (BOX)
Superficial partial thickness wounds Superficial partial thickness - Scalds,
flames, brief contact hot objects
o Damage to upper third of the dermis, leaving a good blood supply
o Pink, moist, and BLANCH (lighten when pressure applied), and blisters form
-Pint to red -Mild to moderate edema
o Increase pain sensation (intense)
-Pain -Blister
o Heals in 10-21 days with no scar with minor pigment changes
-No eschar -Healing in 2 weeks
-No skin grafts
Deep partial thickness wounds
o Damage is deeper into the dermis Classification of burn depth (BOX)
o Blisters generally do not form Deep partial thickness - Scalds, grease and
o Wound surface is red, dry, with white areas in deeper parts, chemicals
o When pressure is applied it blanches slowly or not at all
o Edema moderate, less pain than superficial wounds because more nerve endings are destroy ed-Red to white -Moderate edema
o Blood flow is reduced -Pain -Blisters are rare
o Hypoxia and ischemia can occur -Soft and dry eschar -Healing in 2-6 wks
o Hydration, nutrition and O2 is needed for regrowth -Graft can be used for prolonged healing
o Can convert to full thickness wounds due to infection, hypoxia and ischemia
o Heal in 2-6 weeks with scar formation
o May need skin graft
Classification of burn depth
(BOX)
Full-thickness wounds Full thickness - Scalds; tar,
grease, chemical and
o Destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. electricity
o This skin does not regrow, closes by wound contraction and skin grafting.
o Hard-dry ESCHAR that forms -Black, brown, yellow, white
o THE ESCHAR IS DEAD TISSUE AND MUST SLOUGH OFF OR BE REMOVED FOR HEALING TO OCCUR and red
o Edema is severe under the eschar in a full thickness wound
-Severe edema
Blood flow and chest movement for breathing may be compromised by tight eschar
-Yes and no pain
o Escharotomies (incisions through the eschar)
-No blisters
o Fasciotomies (incisions through the eschar and fascia)
-Hard and inelastic eschar
o May be needed to relieve pressure and allow normal blood flow and breathing
-Healing weeks-months
o Waxy white, deep red, yellow, brown or black
-Skin graft is needed
o Sensation is reduced or absent
o Healing time depends on establishing a good blood supply
o Weeks to months
Deep Full-Thickness Wounds
Classification of burn depth (BOX) Deep
o Extend beyond the skin, damaging muscle, bone, and tendons
full thickness - Flames; electricity, grease,
o Appears blackened and depressed and sensation is completely absent
tar, chemicals
o All full thickness burns need early excision and grafting
-Black -No edema
o Grafting decreases pain and length of recovery
-No pain -No blister
o Amputation may be needed when an extremity is involved
-Hard and inelastic eschar
-Healing weeks-months
-Skin graft is needed
, Class of burns and criteria (BOX)
Minor burns
-Partial <10% TBSA
-Full <2% TBSA
-Younger than 60 years old
Moderate burns
-Partial 15-25% TBSA
-Full 2-10% TBSA
-Younger than 60 years old
Major burns
-Partial >25% TBSA
-Full >10% TBSA
-Involving eyes, ears, face, hands, feet,
perineum
-Electrical injury
-Older than 60 years old
-Other chronic metabolic disorders
Vascular changes
- Fluid shift
o blood vessels near burn dilate and leak fluid into interstitial space.
- Third spacing or capillary leak syndrome TACHY AND HYPOTEN
o continuous leak of plasma from vascular space to interstitial space
- The impaired FLUID AND ELECTROLYTE leads to decreased blood volume and decreased BP
o Edema occurs throughout the body
o Excessive weight gain occurs in the first 12 hours after the burn
▪ Can continue for 24-36 hours
- Profound disruptions of FLUID AND ELECTROLYTE balance and acid-base balance often include
o hypovolemia, metabolic acidosis, hyperkalemia, and hyponatremia
o Hyperkalemia
▪ Direct cell injury releasing large amounts of potassium
o Hyponatremia
▪ Retained sodium in the interstitial space due to stress (RAAS)
▪ Aldosterone increases increasing sodium reabsorption by kidneys
- Hemoconcentration (elevated blood osmolarity, hematocrit, and hemoglobin) develop from vascular dehydration.
- FLUID REMOBILIZATION starts roughly 24 hours after injury
, o capillary leak stops
- Diuretic stage begins at about 48-72 hours after the fluid shifts back into the intravascular space
o Blood volume increases in the kidney
o Diuresis occurs unless kidneys are damaged
o Body weight becomes normal over the next few days as edema subsides
o Hyponatremia and hypokalemia
o Anemia occurs due to hemodilution
▪ Not severe enough for blood transfusion
▪ Transfusions are needed if hematocrit is < 20-25% with s/s of hypoxia
o Protein continues to be lost from the wounds
o Metabolic acidosis is possible due to the loss of bicarb in the urine and increase rate of metabolism
Cardiac changes
- Heart rate increases resp and glucose increase
- Cardiac output decreases
o Due to hypovolemia
o May remain low until 18-36 hours after injury
o Improves with fluid resuscitation
- Fluid replacement and oxygen prevent further complications
Pulmonary Changes
- Direct injury to the lungs from flames rarely occur
- Most problems caused by:
o superheated air, steam, toxic fumes, or smoke
- Such problems are a major cause of death in patients with burns and occur mostly when the burn takes place indoors
- Injuries from burns that cause RF:
o Airway edema, pulmonary capillary leak, chest burns and CO2 poisoning
- Respiratory damage can occur in the upper and major airways and the lung tissue
o Upper airway affected
▪ Inhale of smoke causing edema of the mouth and throat causing airway obstruction
- Smoke and gas slow the ciliated membranes lining the trachea down allowing particles to enter the bronchi
o Lining may slough 48-72 hours after injury and obstruct the lower airway
- Lung tissue damage results from toxic irritant
o Damage to the alveoli and capillaries
o Leaky capillaries can cause alveolar edema
▪ Can occur immediately or up to a week of the injury
o Fluid that diffuses into the lung tissue spaces contain proteins forming fibrinous membranes
▪ leading to respiratory distress
o Progressive pulmonary failure develops
▪ leading to pulmonary insufficiency and infection
Gastrointestinal Changes
- Blood flow is decreased due to decreased cardiac output
- TISSUE INTEGRITY AND MOTILITY are impaired
- Sympathetic system release
o Epi and norepinephrine
▪ Decreasing GI mobility and reduce blood flow to the area
▪ Peristalsis decreases
• Paralytic ileus may develop
▪ Secretions and gasses collect in the GI tract
• Causing abdominal distention
- Curling’s Ulcer (acute gastroduodenal ulcer that occurs with the stress of severe injury) may develop within 24 hours after the burn
injury due to:
o Reduced GI blood flow and mucosal damage
▪ Decreased gastric mucus production and increased hydrogen ions
• Ulcers may develop
o Less common due to medication treatments
▪ H2 histamine blockers, PPI, and enteral feeding
Metabolic Changes
- Injury greatly increases metabolism (hypermetabolism)
