open injury

closed injury

Cranium, chest, abdomen, pelvis, limbs, spine, spinal cord

Mild and self-repairable

Moderate, generally not life-threatening

Severe, life-threatening or severely disabled after recovery

Overview The repair of wounds is caused by the proliferation of cells and intercellular matrix in the injured area. Completed by filling, connecting wounds or replacing missing tissue.

Repair process Inflammation phase: The period when blood is filled, inflammation occurs, and fibrin is added. Stop bleeding and seal wounds. About 3~5 days Proliferative phase: Granulation tissue proliferates to fill the wound (fibroblast C, endothelium C, new capillaries), and fibroblast C synthesizes collagen f to form scar. 1~2 weeks> Shaping phase: Excessive scar tissue is decomposed and absorbed under the action of enzymes, making the shape close to normal and adapting to functional needs. 1 year

Types of wound healing: primary healing (primary healing): small tissue damage, neat wound edges, and no infection. Tissue repair is based on native cells Second-stage healing (scar healing): there are many tissue defects, uneven wound edges, or infection. Tissue repair is mainly fibrous tissue

Factors affecting wound healing Local factors: Wound infection is the most common

Early infection: 3 to 7 days after injury. Cause: Exudate reabsorption Mid-term infection: 2 to 3 weeks after injury. Cause: eschar falling off Late infection: 1 month after injury. Reason: The wound does not heal for a long time and the resistance decreases Infection is the main complication or cause of death in burn patients

From 5 to 8 days after the injury until the wound heals Superficial second-degree burns leave no scar; Deep second-degree burns leave scars; Third degree burns require skin grafting

Later recovery from extensive or severe burns. Sweat glands are destroyed, and it takes 2-3 years for the body's heat regulation to adjust; Itching and pain caused by second or third degree

palm technique Use the patient's own palm as a measure, That is, the area of ​​the patient's palm after the five fingers are put together is approximately 1% of body surface area. Commonly used for small area burns estimate

First degree burns: also known as erythema burns Nursing exam points Only the epidermal layer is injured, causing Hair layer exists. Manifested as burning pain; The wound skin is red, dry and dehydrated Blisters, local temperature is slightly higher.

Second degree burns: also known as blister burns Superficial second-degree burns: Injure the germinal layer of the epidermis and the superficial dermis. It manifests as severe pain; there are blisters of different sizes on the wound surface, with thin walls, yellow clear liquid inside, flush and moist base, edema, and increased local temperature. Deep second-degree burns: Injure the deep layers of the dermis. It manifests as dull pain; there are blisters on the wound surface, with thicker wall, smaller blisters, pale and flushed base, slightly moist, and slightly low local temperature.

Third degree burn: also called eschar burn Injury to the entire thickness of the skin, including subcutaneous, muscle or bone. It manifests as loss of pain; the wound surface has no blisters, no elasticity, is dry like leather, or waxy white, burnt yellow, or even carbonized into eschar, with edema under the scab, and dendritic embolized blood vessels can be seen.

(1) Mild burns: II° burn area less than 10% (inclusive of 10%) (2) Moderate burns: 11%~30% of II° burn area or III° burn area The total amount is less than 10% (including 10%) (3) Severe burns: the total burn area reaches 31%-50% or the III° area reaches 11%-20% or the total burn area does not reach the above percentage, but shock or inhalation injury or more serious compound injury has occurred. (4) Extremely severe burns: total burn area >50% or III° >20%L

laboratory tests (1) Routine blood examination: When body fluids are insufficient, the blood becomes concentrated; during infection, white blood cells and neutrophils increase. (2) Electrolyte and blood gas analysis and examination: Understand whether the patient has imbalances in water, electrolyte, and acid-base balance.

psychological condition The patient's psychological tolerance for changes in appearance and body shape caused by burns and concerns about permanent disability should be assessed;

Common nursing diagnoses

1. Get rid of the pyrogen quickly 2. To save lives, first deal with critical situations such as suffocation, cardiac arrest, massive bleeding, shock, open or tension pneumothorax, etc. 3. Prevent shock, stabilize the patient's mood, calm down and relieve pain, implement rehydration as soon as possible, avoid drinking boiled water as much as possible, take light saline orally, and open intravenous access for moderate or above burns. 4. Protect burn wounds 5. Sedation and analgesia 6. Forward as soon as possible

Closely observe changes in the patient's consciousness, respiration, blood pressure, pulse, urine output, body temperature and other indicators to determine whether there is shock or systemic infection.

Within 48 hours after burn injury, shock is the main problem for patients. The main nursing measures at this stage are to establish intravenous access and follow the doctor's instructions to replenish the patient's blood volume. You should understand how much fluid to replenish, what fluid to replenish, and how to replenish fluid. The main nursing measure at this stage is to establish intravenous access and follow the doctor's instructions to replenish the patient's blood volume. You should understand three aspects: how much fluid to replenish, what fluid to replenish, and how to replenish fluid.

Calculation of fluid replacement volume

Type of liquid

Rehydration arrangement

Fluid replacement and observation

Proper wound management is key to healing burns. Purpose: Protect the wound, prevent and treat infection, promote healing, and restore function to the maximum extent.

Respiratory burns: You must be vigilant at all times, strengthen observation, and keep the respiratory tract open.

Assist and guide the patient to maintain functional postures. If the neck is burned, the patient should be in the extended position. If the limbs are burned, the patient should be in the straight position. The hand should be fixed in a half-fist position and oil gauze should be placed between the fingers to prevent adhesion.

Local: Local redness and swelling are not obvious, pain is mild, bleeding is small, no exudate, only numbness and swelling, spreading to the proximal limbs. Whole body: dizziness, drowsiness, drooling, hoarseness, difficulty speaking and swallowing, blurred vision, difficulty breathing, unsteady standing, in severe cases, inability to move limbs, paralysis, and involuntary twitching of hands and feet.

Local: Severe pain in the wound, non-stop bleeding, obvious swelling, rapidly spreading to the proximal end, skin purpura and bloody blisters. Whole body: fever, rapid heartbeat, irritability, delirium, extensive bleeding, hemolysis, arrhythmia, shock, etc., which can eventually lead to heart, kidney, brain and other organ failure.

A combination of both, and the patient eventually dies from respiratory paralysis and circulatory failure.