Your pt has a pressure ulcer described as: Partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, blister, or shallow crater.

What stage is it?

Your pt has a pressure ulcer described as: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts.

What stage is it 

Your pt has a pressure ulcer described as: 

Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

What stage is it 

Your pt has a pressure ulcer described as: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues.

What stage is it

Your pt has a pressure ulcer described as: "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

What stage is it

Deep Tissue

Your pt has a pressure ulcer described as: "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Unstageable

Inflammatory Phase 

Hemostasis thorough vasoconstriction (a decrease in the diameter of blood vessels, especially the arteries)

leads to - Platelet aggregation

and 

- Thromboplastin makes clot 

Once Hemostasis is compleat what is initiated and what it's effect on blood vessels?

Inflammation

- Vasodilation (an increase in the diameter of the blood vessels, especially the arteries) 

Margination and Phagocytosis (the engulfment and digestion of bacteria and other foreign cell particles) 

Proliferative Phase 

How long will the Proliferative Phase last?

2 days to 3 weeks 

What three possesses will happen during the Proliferative Phase? 

Granulation,  Contraction, Epithelialization

- Fibroblasts lay bed of collagen

- Fills defect and produces new capillaries 

Crosses moist surface

Cell travel about 3 cm from point of origin in all directions 

Remodeling Phase 

How long will the Remodeling Phase last?

New collagen forms which increases tensile strength to wounds

***Scar tissue is only 80 percent as strong as original tissue ***

What are the Methods of closure of a wound

•  Primary

•  Secondary

•  Tertiary

What is Primary Closure

What is Secondary Closure

What is Tertiary Closure

Wound margins are closed surgically after there is evidence of granulation

(reproximation)

Older age, Diabetes

Immune system disorders, cancer, human immunodeficiency virus infection, and malnutrition

Paralysis or other limited mobility- (wheelchairs, confined to bed)

Hospitalization, which increases risk forinfection by organisms that are resistant to antibiotics

Deficiencies in: B Cells, T Cells, NK Cells

Altered Neutrophil Function

Alterations in immune sensing

Redness, warmth, and tenderness in the area of the wound

Pus-a foul-smelling, yellowish-white fluid coming from the wound

Fever

Elevated WBC 

What are the Mechanisms of Injury for burns

Thermal - burn from a heat source

Chemical - burn from a substance producing a chemical reaction

Electrical - burn from contact with an electrical current

Using the Lund & Browder method how would you determine the extent of a burn

    * Head/neck - 9% TBSA

    * Each arm - 9% TBSA

    * Anterior thorax - 18% TBSA

    * Posterior thorax - 18% TBSA

    * Each leg - 18% TBSA

    * Perineum - 1% TBSA

% of 2nd ° + % of 3rd ° =  total body surface aria burn

2nd° > 20% of TBSAB

or

3rd° > 10% of TBSAB

2nd° > 25% of TBSAB

or

3rd° > 10% of TBSAB

burn accompanied by trauma

pts with complicated med history

( COPD, MI, Autoimmune ect.) 

your pt has a burn that looks wet and weepy

what stage of burn is this

all layers of skin affected may look charred or translucent 

pts with burns on face- indicates smoke inhalation

pts with circumferential burns on neck and chest

tissue recutment- prevent further damage to tissue. 

removal of dead tissue, cleaning and bandaging open wounds. 

Modern burn care may be divided into  4 general phases, What are they?

first phase- initial evaluation and resuscitation

second phase- initial wound excision and biologic closure

third phase- definitive wound closure

fourth phase-  rehabilitation

evaluation for other injuries and comorbid conditions.

reconstruction, and reintegration. Although this begins during the resuscitation period, it becomes time-consuming and involved toward the end of the acute hospital stay.

inflammatory reaction- hypovolemia 

release of MDF- decreases contractility, leads to arthymias 

air way edema → obstuction in the first 4-6 hours

hypoxia/hypercarbia → pulmonarry edema →ARDS

or direcct inhilation of toxic chemicals

carbo monoxide- buring of woods and common material

cyanide- hard plastics are burned 

hydrogen chloride- burning lanolium 

syncopy 

singed nasal hairs 

fire was in a closed area

soot around nose or mouth

respitory distress

upper airway obstuction- cuased by edema 6-24 hrs

pain- give pain meds

neuropathy

deformity

nausea/ileus in first 24 hrs- from inflammatory process

stress ulcers

hypermetabolic

abdominal HTN - from fluid resuscitation

keep pt well hydrated 

strict I/O's

out put needs to be > 30 cc per hour

(may have stricter guidelines of > 50-80 cc per hour)

What is a Level I (Trauma Center)

Comprehensive care by a minimum of  1 EMD 24hr/day in the ED

In house coverage of :  medicine, surgery, OB/GYN, pediatrics, and anesthesia 24hr/day

Other specialties available within 30 minutes

Definitive care for physical and emotional problems in-house

What is a level 2 Trauma Center

Comprehensive care by a minimum of 1 EMD 24hr/day in the ED

All specialty consults available to the hospital within 30 minutes

What is a level 3 Trauma Center

Emergency Care 24hr/day provided by an MD available to the ED within 30 minutes

What is a level 4 Trauma Center

Provides life saving first aid and makes appropriate referral to the nearest capable facility

What is the Nursing Triage Assessment-

Grade 1-3 or 1-5; 1 being the most critical and need immediate attention

Vital signs

Review of symptoms

Medications

Allergies

Mechanism of injury

What type of  tramma cases must you report to Law Enforcement

MVA

GSW / Stabbing

NAT (anyone)

Sexual Assault

Suicide

Drug Abuse

What type of  tramma cases must you report to the Health Department

Successful suicide

Communicable disease

Preserve life

Prevent deterioration before definitive treatment

Restoration to pre-injury state

any object that has gone through the skin and is protruding from the pt. 

examlpe- knife, rebare branches 

Structures injured are related to path of travel

Acceleration

 Deceleration- Coup Contrecoup Injuries

 Shearing- Diffuse Axonal Injury

 Compression- Spinal Cord injury

Spleen rupture

Liver rupture

Any organ rupture

Pericarditis

Pneumo/hemo thorax

Fractures

Contusion

Shearing/rupture of vessels

Laceration or wounds due to impact on internal bone structures

A purplish, flat bruise that occurs when blood leaks out into the top layers of skin

How old is a bruise that appears purple edematous/tender

What are the physical indicators of physical child/elder/adult abuse:

Bite marks. Bruises on uncommonly injured body surfaces.

Lacerations. Burns.

High incidence of accidents or frequent injuries.

Fractures/broken bones in unusual places such as the skull, ribs etc.

Injuries, swellings to face and extremities.

Discoloration of skin. Blunt-instrument marks. Human hand marks.

Multiple injuries at different stages of healing.

Evidence of poor care/failure to thrive. 

What Prescription drugs have a impact on the out come of trauma pts

Anti-hypertensives-may not be able to bring bp up or vasso constrict

Antiarrhythmics

NSAID’s

Anti-coagulants

Narcotics

Over-the-counter

Herbal remedies

Illicit drugs

       CNS stimulants

       CNS depressants

A = Airway

B = Breathing

C = Circulation

D = Disability (neuro checks)

E = Exposure

what do you do when assessing for D = Disability

(neuro checks)

GCS:  13-15 = mild head injury

GCS:  9-12 = moderate head injury

GCS:  3-8 = severe head injury

what do you do when assessing for E = Exposure

strip pt, need to see every inch assess for 

DCAP (deformity, contusion, abrasion, punctures)

BTLS (burns, tenderness, lacerations, swelling)

Determine Mechanism of Injury

Chief complaint  (if responsive)

Rapid head to toe (if unresponsive)

X-rays: skull, C-spine, chest, specifics

and /or EKG

CBC, BMP, Type and Cross, Coags, ABG’s,

Toxicology, UA

IVx2 16 gage, monitor, foley, NG, meds 

DCAP-BTLS 

Ears: bleeding, discharge, bruising behind the ears

Pupils: quality, reactivity, raccoon eyes, impaled objects

Mouth: re-check airway, dentures, loose or broken teeth, occlusions, bleeding, gag reflex, vomitus, breathing

Consider C Spine Immobilization

DCAP-BTLS,  

JVD, Tracheal deviation

C-Spine: deformity or tenderness

Accessory muscle use

Blunt trauma

Burns

DCAP-BTLS

Equal chest rise and fall

Open wounds, air leaks

Breath sounds

DCAP-BTLS

Pulsating mass

Palpate 4 quadrants- Tenderness, guarding

Distention

Signs of pregnancy (consider possible placental abruption, premature labor)

Consider: Liver laceration/splenic laceration,, aortic dissection

DCAP-BTLS

Assess for instability

Priapism

Bleeding or discharge

Consider: Pelvic fracture, hemorrhage

DCAP-BTLS

Pulse, movement, sensation

Consider: Femur fracture and pulmonary embolism,hemorrhage, Neurovascular compromise

What assessment of the posterior needs to be done on a pt that has come to the ED with traumatic injuries.

( this will need to be done all at once, with the help of the team to log roll the pt)

DCAP-BTLS

Lung sounds

Skin wounds or lesions

Consider: dependent pooling of blood

DCAP-BTLS 

Assess pulses, movement, sensation

Consider: Neurovascular compromise

S =   Signs & symptoms

A =  Allergies

M = Medications

P =  Past medical history (heart, lung, kidney, liver, brain)

L =  Last oral intake (solids and/or fluids)

E =  Events leading to illness or injury