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Dermal Integrity

Burns

Depth

• First degree burns – No blistering. Limited to the epidermis. Do not consider first degree burns when assessing total surface area of the burn. These do not affect outcome or factor into electrolyte management.
• Second degree burns – Blistering and penetrate at least partially into the dermis.
• Third degree burns – Completely through the dermis to the fat layer beneath. May be less painful

Location

• The rule of nines is a way to estimate body surface area affected and assess location of the burns
  • Palm is 1%
  • Head and neck 9%
  • Each arm is 9%
  • Each leg is 18%
  • Anterior trunk 18%
  • Posterior trunk 18%
  • Genitalia 1%

Treatment

• First degree burns can be treated with cool compresses
• Second and third degree burns are both treated as full thickness burns
  • Supportive care
  • Fluids
  • Clean and dress wounds
  • Use silver sulfadiazine to protect wounds from infection
• Fluids and Electrolytes
  • Parkland formula for fluid in the first 24 hours
    • TBSA burned (%) x Wt (kg) x 4 ml of Lactated Ringers
    • Give half in the first 8 hours. Give the second half over the next 16 hours.
    • Example: 180 lb man with both arms completely burned
      • 81 kg x 18 x 4 = 5832 ml = 5.9 liters lets round to 6 liters
      • Give 3 liters of Ringer’s Lactate in the first 8 hours and 3 liters over the next 16 hours.
• Monitor urine output
• Tetanus shot
• Surgery
  • Debridement and skin grafting is often necessary especially for deep second degree and third degree burns

Chronic Venous Insufficiency

• Weakened vessel walls and incompetent valves generally in the lower extremities

Clinical Presentation

• Progressive edema beginning at the ankles and moving up
• Skin changes
  – Hyper-pigmentation
  – Shiny
  – Atrophic
  – Dermatitis

Physical Exam Findings

• Progressive edema beginning at the ankles and moving up
• Skin changes
  – Hyper-pigmentation
  – Shiny
  – Atrophic
  – Dermatitis
  – Ulcerations (PAINLESS? less pain than PVD ulcers)

Labs & Studies

• U/S doppler

Treatment

• Behavioral changes
  • Avoid long periods of standing
  • Elevate legs when possible
  • Graduated elastic stockings
  • Heat
  • Ambulatory exercise

Pressure or Decubitus Ulcer (Bed Sores)

Local tissue damage due to decreased blood flow secondary to prolonged pressure. Typically occurs over a bony prominence like the sacrum, coccyx, heels and hips.

Stages of Ulcers

• Stage One
  • Erythema, skin is intact
• Stage Two
  • Shallow ulcer – superficial or partial thickness
• Stage Three
  • Deep full thickness ulcer. these go down to the fascia
• Stage Four
  • Necrosis and necrosis including bone, muscle and other structures
• Osteomyelitis and sepsis may be serious secondary issues

Treatment

• Prevention is Key!!! Find a way to redistribute pressure.
  • Turn patients
  • Padding for the heels and sacram
  • Air fluid beds (Clinitron)
• Maintain nutrition
• Hygiene
• Surgical debridement when necessary.

Study tip

Integrity