Burns, Wounds and Scars

3.3 & 3.6

periwound

skin surrounding the wound

tunnel

a wound that is deeper than it is wide (extends into tissue below)

underminining

a wound that is wider than it is deep

factors included in a wound assessment

margins, base, exudate, odor, periwound, necrosis, pain

maceration

white periwound due to excess moisture

necrotic tissue

dead tissue; eschar (dry) or slough (moist)

granulation tissue

beefy red (replaced dead tissue)

hypergranulation

forms above the skin’s surface; delays epithelization

epithelial tissue

pink or light purple, bumpy

keloid scar

scar tissue that extends beyond the border of the wound; unorganized collagen, painful and itchy, continues to grow over time; large, bulging scar caused by abnormal amounts of collagen

hypertrophic scar

raised scar tissue that remains within wound boundaries; most common after surgeries and burns, itchy, naturally gradually decreases in size, associated with contractures and may appear red or dark in color. h

hypertrophic scar treatment

silicone or pressure dressings (increase moisture and decrease O2 in the area), manual therapy massage

dehiscence

wound pulls apart

denude

damaged skin from moisture

hemosiderin staining

brown skin discoloration due to vascular incompetence

crepitus

gas bubbles underneath the skin; send pt to ED if suspected (indicates necrotizing fascitis)

normal exudate

clear, thin

normal odor

none

normal periwound

should look and feel like normal skin

yeast infection indication

red spots with periwound

signs of infection

erythema, pain, swelling, heat, fever, odor, increased exudate, failure of wound to progress

cardiovascular disease effects on wounds

decreased circulating oxygen and blood flow to wound

respiratory disease effects on wounds

decreased circulating oxygen, stress on body

GI disease effects on wounds

poor overall nutrition and lack of nutrients to aid with healing

MSK disease effects on wounds

greater risk for skin breakdown, slow healing, decreased mobility, impaired sensation, impaired cognition

endocrine disease effects on wounds

abnormal glucose levels impair healing, higher risk for skin breakdown

skin properties

protection against infection and trauma, regulation of body temperature, sensory functions, fluid and electrolyte maintenance, vitamin D synthesis, cosmesis

thermal burn

caused by exposure to a heat source (flames, liquids, steam, hot objects)

chemical burn

caused by tissue contact or ingestion, inhalation or injection of chemical compounds

electrical burn

caused by heat that is generated by the electrical energy as it passes through the body

radiation burn

caused by contact with a radioactive source (treatment for cancer)

CV impact of burns

decreased BP, intravascular pressure, decreased myocardial contractility, reflex tachycardia, cardiac dysrhythmias

superficial burn

first degree; like a sunburn

partial thickness burn

second degree; superficial partial or deep partial thickness

full thickness burn

third degree; through the dermis, requires grafting (will otherwise heal as scar tissue)

first degree burn characteristics - superficial

pink-red, 3-5 day resolution, localized inflammatory response

epidermal involvement only

second degree burn characteristics - superficial partial

moist, frequently see blistering, very painful, blanches with pressure, heals in 7-14 days, usually no grafting

epidermis and superficial dermis involved

second degree burn characteristics - deep partial

less painful, can feel like pressure, less moist, healing may take 4-6 weeks, may require grafting, deep red-pink

epidermis and deep dermis involved

third degree burn characteristics - full thickness

may appear waxy white, cherry red, charred, or leathery, dry, hairless, minimal pain initially, absent sensation, grafting required

full thickness

fourth degree burn characteristics - sub dermal

burn extends through all layers of skin and can include fat, muscle, tendon, and/or bone; not appropriate for grafting; black, charred appearance; requires amputation/excision