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Unit 7 – Tissue Integrity ### Concept - Thermoregulation: The process of maintaining core body temperature at a near constant value. - Tissue Integrity: Structurally intact and physiologically functioning epithelial tissues, including the integument (skin) and mucous membranes. #### Exemplar - Burns ## Burn Injuries - Approximately 398,000 people require medical attention for burns every year. - About 3,800 persons die from burns and associated inhalation injuries each year. - 41% of all burn admissions result from fires or flames. - 31% result from scalding injuries (liquid burns). - Most burns occur in the home. - High-risk groups: Young children and the elderly. - Nurses play a crucial role in the prevention of burn injuries by teaching prevention concepts and promoting safety legislation.
Phases of Burn Care
The management of burn injuries typically follows three distinct phases:
1. Emergent (Resuscitative) Phase
- Onset: From the time of injury to the completion of fluid resuscitation.
- Duration: Usually the first 24 to 48 hours.
- Priorities:
- Airway Management: Securing the airway, especially for facial burns or inhalation injury. Intubation may be necessary.
- Fluid Resuscitation: Critical to prevent burn shock, guided by formulas like the Parkland formula (4 \text{ mL} \times \text{kg} \times \text{% TBSA burn} for crystalloid over 24 hours, half in first 8 hours).
- Pain Management: Administering analgesics intravenously due to impaired circulation subQ/IM.
- Wound Care:
- Initial cleaning and covering with clean, dry dressings to prevent heat loss and contamination.
- Debridement: Minimal debridement of loose skin/blisters may occur, but extensive debridement is usually delayed.
- Temperature Control: Maintaining body temperature to prevent hypothermia.
- Assessment: Continuous monitoring for inhalation injury, associated trauma, and overall physiological response.
2. Acute Phase
- Onset: Begins with the start of diuresis and ends when the burn wound is fully covered by skin grafts or healing is complete.
- Duration: Weeks to months.
- Priorities:
- Wound Healing:
- Cleaning and Dressing Changes: Daily or twice-daily, using specialized topical antimicrobial agents (e.g., silver sulfadiazine, bacitracin).
- Debridement: Essential for removing necrotic tissue (eschar) to promote healing and prevent infection.
- Types of Debridement:
- Surgical (Excisional): Performed early (within 24-72 hours) to remove necrotic tissue down to viable tissue, followed by skin grafting.
- Mechanical: Scrubbing or using wet-to-dry dressings to remove loose eschar. Less common now due to pain and trauma.
- Enzymatic: Topical application of enzymatic agents (e.g., collagenase) to dissolve eschar.
- Autolytic: Using moisture-retentive dressings to allow the body's own enzymes to break down necrotic tissue.
- Types of Debridement:
- Infection Control: Strict aseptic technique during wound care, monitoring for signs of infection.
- Nutritional Support: High protein, high calorie diet is crucial due to hypermetabolic state.
- Pain Management: Continued systematic and sometimes procedural pain management.
- Psychosocial Support: Addressing patient and family emotional needs.
- Physical and Occupational Therapy: Initiating early range-of-motion exercises to prevent contractures.
- Wound Healing:
3. Rehabilitative Phase
- Onset: Begins when wound closure is achieved and continues for years, or even a lifetime.
- Priorities:
- Functional Restoration: Maximizing physical and psychosocial function.
- Scar Management:
- Pressure Garments: Worn continuously to minimize hypertrophic scarring and keloid formation.
- Massage and Moisturizing: To keep skin pliable and reduce itching.
- Splinting and Positioning: To prevent contractures and promote joint mobility.
- Cosmetic Reconstruction: Surgical interventions to improve appearance and function.
- Psychosocial Adjustment: Support for body image issues, PTSD, and reintegration into society.
- Prevention of Complications: Long-term monitoring for chronic pain, itching, and joint limitations.