| 3 steps of tissue healing: | - inflammatory,
- proliferation,
- maturation/remodeling |
| eliminates invading organisms and removes foreign material.
vascular response –
o vasoconstriction to control bleeding
o increased vascular permeability
o after bleeding under control, vasodilation occurs
cellular response – neutrophils and macrophages
combination of intense vasodilation and increased vascular permeability leads to inflammation
o rubor
o tumor
o calor
o dolor | inflammatory step of tissue healing |
| redness | rubor |
| swelling | tumor |
| heat | calor |
| pain | dolor |
| fill wound defect with granulation tissue
fibroblasts are primary cells of this phase.
2 events occur:
• synthesis of extracellular matrix
• re-creation of blood supply (angiogenesis and arteriogenesis) | proliferation step of tissue healing |
| increase of tensile strength of collagen.
• equal breakdown of collagen synthesis to degradation
• wound is only 80% original tensile strength
• wound changes from being highly vascular and cellular to acellular and avascular.
• Process may require 1-2 years complete | maturation/re-modeling step of tissue healing |
| factors that lead to risk of hypertrophic scarring: | - young age,
- female,
- darker pigmented skin,
- neck or upper limb burns,
- multiple surgical procedures,
- >3 weeks to heal,
- meshed skin graft use |
| properties of a mature scar: | - soft,
- pliable,
- flat,
- normal vascularity |
| properties of a scar still healing: | - thick and firm,
- raised,
- not pliable,
- red/pink in color,
- blanch with pressure |
| importance of debriding a blister: | to prevent infection and to help with ROM |
| burn depths that require a skin graft: | - deep partial thickness,
- full thickness |
| these grafts scar, a meshed or sheet graft is used | split thickness |
| these grafts don't tend to scar, used on small areas, better cosmetic outcome, takes all epidermis and dermis. | full thickness |
| type of graft: temporary coverage, prepares dermis for autografting, body will reject and should be removed/replaced in 5-10 days. | Allograft (homograft) |
| type of graft: permanent skin coverage, grafts protected or scoured by negative pressure, bandages, or cast/splint, angiogenesis begins within 24 hours. | Autograft |
| type of graft: temporary coverage, skin from a different species, can be from a pig, fish, pig or sheep organs | xenograft |
| importance of immobilization after a skin graft: | Should be immobilized for 3-5 days because graft site is fragile and must be protected from shear forces, excessive pressure, and movement. |
| factors that can affect the success or failure of a skin graft: | • Infection,
• Inadequate debridement,
• Insufficient immobilization,
• Collection of fluid under graft |
| incision made into insensate, full thickness burned tissue and into the subcutaneous tissue to relieve constricting circulation and help with blood flow. Done on arm, leg, trunk, hands, or feet; over areas that won’t cause issues with positioning. | Escharotomies |
| incision to muscle fascia beneath burned tissue performed in pts with very deep burns involving the fascia and muscle, associated traumatic limb injuries, high voltage electrical injuries. | Fasciotomies |
| effects on the donor site when using an autograft: | • Donor site is where the graft comes from,
• Skin used for grafting that creates a partial thickness wound.
• Heals within 10-14 days,
• Usually more painful than graft site,
• Moderate to copious amounts of drainage,
• More commonly treated with transparent film, xeroform, or skin substitute. |
| What is the rule of 9's? | Separates the body into 9% sections.
o The head (front and back) – 9%,
o upper chest (front or back) – 9% each,
o lower chest (front or back) – 9% each,
o legs (front or back) 9% each,
o arms (front and back) – 9%,
o genitals – 1%. |
| What is the rule of 9's for adults? | o head – 9%,
o upper and lower chest (front and back) – 18%,
o arms – 9%,
o legs – 18%. |
| What is the rule of 9's for children? | o head – 18%,
o arms – 9%,
o upper and lower chest (front and back) – 18%,
o legs – 14%. |
| will occur from normal inflammation and additional fluids. Monitor pulses hourly with a doppler US, escharotomies and/or fasciotomies may be warranted. | Edema |
| large amounts of fluid are lost through third spacing and burned areas. If proper resuscitation is not performed, pt may experience burn shock from hypovolemia and tissue ischemia. Replacement of intravascular volume in the form of this must continue until organ tissue perfusion has been restored. | Fluid resuscitation |
| help protect against infection. Sometimes debriding is necessary to regain ROM, gently clean after blister breaks | blisters |
| best to excise deep burn wounds and use appropriate topical management and dressings for burn to keep this from happening. | Infection control |
| it is best to maintain soft tissue elongation with anticontracture positioning and maintaining and progressing ROM. | tissue shortening |
| because the cardiovascular system and metabolism is effected by burn, causes issues with this. To counteract these changes, always keep them moving and use compression to help with edema and circulation. | circulation |
| positioning is important to help with tissue elongation as well as exercises to keep their this improving. | ROM |
| this helps to avoid contractures and to keep them comfortable as they’re healing. | Positioning |
| why can edema can be detrimental to the burn healing process? | if not treated it can cause compartment syndrome, when too much pressure is present on nerves and arteries from increased fluid, rigid skin, and a circumferential burn. |
| burn edema timeline: | Edema formation is rapid, between 2-3 hours post burn.
o Its maximal by 8-12 hours in a small burn and in 12-24 hours in a large burn.
o It persists at a high level for 48-72 hours.
o Slow resorption begins and should resolve in 7-10 days by may persist for 2-3 weeks. |
| how is the cardiovascular system effected by burns? | - cardiac output increased to normal by 18-24 hours but then doubles until wounds are closed.
- HR is increased leaving the body prepared for ROM or mobility.
- Low mean arterial pressure indicates reassessment of fluid volume, High mean arterial pressure may necessitate a change in pain management. |
| how is the pulmonary system effected by burns? | - infection can develop within 2 days to 2 weeks from prolonged bedrest,
- inadequate pulmonary toilet, and
- decreased immune response.
- With inhalation injury, 40% develop pneumonia. |
| how is the immune system effected by burns? | - endogenous and exogenous bacteria can invade burned skin and
- decreased tissue perfusion reduces mobility of immune cells. |
| how is the renal system effected by burns? | hourly urine output goal is 30-50 ml/hr. |
| how is the neuromuscular system effected by burns? | neuropathy is noted in 12-15% of pts with burns. |
| What are the metabolic effects s/p burn? | - severe burns cause elevated body temp,
- increased oxygen consumption,
- increased glucose production,
- muscle weakness,
- cardiopulmonary deconditioning.
- The tissue also degrades, causing decreased lean body mass, bone mineral content, and bone mineral density. |
| What are the nutritional effects s/p burn? | - healing from a burn requires more calories and protein to be taken in.
- Since the body needs more nutrients, tube feeding is common. |
| What are the psychological effects s/p burn? | - the psychological state can have the most effect on outcomes.
- Can cause acute anxiety, fear, hallucination, and sleep disorders.
- Also, extent of damage and impact on life becomes.
- Evident, depression and PTSD occur as well. Pt most likely will require psychological help. |
| What interventions are done with gait for burns? | - can do LE exercises with feet hanging off bed, prior to gait.
- Apply pressure through feet while sitting and always keep the pt moving, do not stand in one spot.
- Encourage heel to toe and foot flat. |
| What interventions are done with mobilization for burns? | early mobilization is safe and feasible resulting in decreased pneumonia and DVT and airway, pulmonary, and vascular complications. |
| What interventions are done with exercise for burns? | - exercise begins day 1.
- Always encourage active motion and perform passive motion cautiously when pt is sedated.
- Best to perform PROM or AAROM with dressings off to prevent additional skin damage or joint damage.
- When stretching a scar, when it’s white, it’s tight. |
| why is static dependent positioning painful to a pt after a burn? | it doesn’t help with pliability of scar and is painful because it can cause contractures. |
| Who's at a higher risk for developing contractures after burns? | • Burns over flexor surface or lateral to flexor surface,
• Non-compliant pts who maintain “position of comfort”,
• Excessive, prolonged edema,
• Deep partial and full thickness burn injuries,
• Destruction of tendon or muscle,
• Hypertrophic scarring,
• Prolonged immobilization,
• Heterotrophic ossification,
• Degree and quality of movement is poor |
| What is the purpose of a compression garment? | - Compression relieves edema,
- inhibits growth of hypertrophic scar,
- promotes scar maturation,
- protect newly healed skin,
- relieves itching, and
- relieves pain. |
| how often should a compression garment be worn? | 23 hours of the day and only taken off for bathing. |
| when is it safe to discontinue wearing a compression garment? | May discontinue when scars are flat, all increased redness/color has faded. Remove for a trial period of 2-3 days to see how the scar does.
o If scar remains flat with no increase in color, may discontinue. Resume garments if scar begins hard and red again. |
| What is the appropriate positioning to minimize contractures after a burn injury? | o Foam,
o Rolled towels or blankets,
o Pillows,
o Various custom and manufactured orthotics/casts.
o Surgical procedure; sutures, percutaneous pins, Negative Pressure Wound Therapy. |
