Necrotizing Faciitis Fascia are covering tissues Loose connective tissues such as superficial fascia or subcutaneous tissue permits

ts movement of the skin. Deep facia are dense, irregular tissue covering and binding muscles. Necrotizing (killing of, death of) Fasciitis (inflammation of skins fascia) Uncommon, usually acute, severe infection involving the supeficial and deep fascia. Can affect various part of the body e.g. abdbominal wall, perianal groin, face neck, chest. Commonly affects the extremities esp. the legs. 3 Major elements of general Infection 1. abilities of the organism ( characteristic of microorg) 2. point of entry (anatomical location) 3. host defense status ( host response/clinical s&sx) Differentiation of skin, soft tissue and muscle infectious condition : Cellutitis, NF (Type I & Type II), synergistic NF, clostridial myonecrosis. GANGRENE- death of tissue due to lack of bld flow. Dry gangrene aseptic death of tissue due to lack of blood flow. CELLULITIS an acute spreading infection of the skin the involves subcutaneous tissue Streptococcal or staphylococcal bac. Grp. A Streptococcus (GAS) etc Gangrenous cellulitis NECROTIZING FASCITIIS TYPE I Nonstreptococcal cause that involves multiple soft tissue layers and is often classified under subcutaneous tissue infections. Causes of NF TYPE I: 1. bacteriodes spp., anerobic species , gram (-) rod bac. 2. peptostreptococcus spp., anerobic species, gram (+) cocci bac. 3. Facultative ( living in certain condition) anerobic species od strep. 4. Enterobacter spp., E Coli. gram (-) rod bac. GAS (Group A Streptococcus) Streptococcus Pyogenes Found in throat and skin 6 virulence factor of GAS 1. special protein for adherence and colonization 2. immunogenic disguise w/ ability of antigenic variation and tolerance 3. kills and inhibits phagocytes

 4. ability to produce protein splitting enzymes allowing bac. Multiplication 5. release of exotoxins 6. ability to induce exaggerated production of cytokines resulting to systemic toxicity. FOURNIERS GANGRENE NF occuring at the male genitalia and ma extend to the perinium, penis and abdominal wall Starts as cellulitis At risk if with DM, local trauma, perirectal & perianal infxn. CRANIOFACIAL AND CERVICAL NF Caused by GAS, precipitated by trauma, dental, oral, or pharygeal infxn. CLOSTRIDIAL MYONECROSIS Involves muscle, the skin is yellow-bronze and bullae contains dark brown fluid RISK FACTORS: DM, Cirrhosis, Alcoholism, PVD, CA, Parenteral IV drug abuse, dependency on renal dialysis Impaired lymphatic drainage Chronic corticosteroid intake S & SX Point of entry may be obvious, minor or none NSAID use delays diagnosis and reduce inflam features Fever, severe pain (local or referred) Disproportionate pain to the appearing injury Flulike symp., nausea, weakness, malaise, diarrhea, dizziness Local erythema to purplish rash may appear on area Crepitus seen w/ type I NF Bullae Diagnosis ETC Imaging Soft tissue X-rays, CT, MRI Can reveal gas in the tissues, but not as good as direct surgical exploration Cultures Blood Cx positive in 60% with type II, 20% with type I

 Surgical wound cultures almost always positive First line treatment Make prompt diagnosis Provide antibiotic therapy Encourage aggressive debridement Treatment Administer ancillary therapies (IV immunoglobulins, hyperbaric O2 Early and aggressive surgical exploration and debridement Reexploration should be performed w/in 24 hrs Broad Antibiotic therapy Type I: ampicillin or unasyn with clindamycin or flagyl If recent hospitalization, use zosyn or timentin instead of unasyn. Type II: PCN G and clindamycin; vancomycin Hemodynamic support Intravenous immunoglobulin (currently under investigation, but not recommended) Hyperbaric oxygen therapy Nursing responsibilities Obtain accurate health Hx esp those taking corticosteroids Investigate and report severe pain (disproportionate pain to condition) Assess, tx. & reassess pain esp for effectiveness of intervention Monitor and report pt.s statement of unexplainable or unusual pain on site Monitor fever and skin changes to affected area ETC.. Read 323-324 Patient Teaching Good hand washing, Avoid contact w/ person showing sore throat sx esp with known GAS exposure Educate pt. to clean trauma area no matter how small by washing and using antibiotic ointment Educate the public regarding NF its risk factor, potential condition. Provide information regarding NF. BURN A grp. of condition w/ outcomes that include the removal of skin by thermal (heat or radiation), chemical, or electrical means. Types Thermal exposure to flame or a hot object Chemical exposure to acid, alkali or organic substances

 Electrical result from the conversion of electrical energy into heat. Extent of injury depends on the type of current, the pathway of flow, local tissue resistance, and duration of contact Radiation result from radiant energy being transferred to the body resulting in production of cellular toxins Burn Wound Assessment Classified according to depth of injury and extent of body surface area involved Burn wounds differentiated depending on the level of dermis and subcutaneous tissue involved 1. superficial (first-degree) 2. deep (second-degree) 3. full thickness (third and fourth degree) Superficila burn (first degree) Epidermal tissue only affected Erythema, blanching on pressure, mild swelling no vesicles or blister initially Not serious unless large areas involved i.e. sunburn Deep (second degree) Involves the epidermis and deep layer of the dermis Fluid-filled vesicles red, shiny, wet, severe pain Hospitalization required if over 25% of body surface involved i.e. tar burn, flame Full Thickness (third/fourth degree) Destruction of all skin layers Requires immediate hospitalization Dry, waxy white, leathery, or hard skin, no pain Exposure to flames, electricity or chemicals can cause 3rd degree burns Rule of Nine ADULT Head & Neck = 9% (4.5+4.5 AP) Each upper extremity (Arms) = 9% (4.5+4.5 AP) Each lower extremity (Legs) = 18% (9+9 AP) Anterior trunk= 18% (9+9 ant. chest/abdomen) Posterior trunk = 18% (9+9 post upper/ lower back) Genitalia (perineum) = 1% PEDIA Head = 18% Each upper extremity (Arms) = 9% (4.5+4.5 AP)

Each lower extremity (Legs) = 14% (9+9 AP) Anterior trunk= 18% Posterior trunk = 18% Genitalia (perineum) = 1%

VASCULAR CHANGES RESULTING FROM BURN INJURIES Circulatory disruption occurs at the burn site immediately after a burn injury Blood flow decreases or cease due to occluded blood vessels Damaged macrophages within the tissues release chemicals that cause constriction of vessel Blood vessel thrombosis may occur causing necrosis Macrophage: A type of white blood that ingests (takes in) foreign material. Macrophages are key players in the immune response to foreign invaders such as infectious microorganisms. Fluid shift Occurs after initial vasoconstriction, then dilation Blood vessels dilate and leak fluid into the interstitial space Known as third spacing or capillary leak syndrome Causes decreased blood volume and blood pressure Occurs within the first 12 hours after the burn and can continue to up to 36 hours Fluid Imbalances Occur as a result of fluid shift and cell damage Hypovolemia

Metabolic acidosis Hyperkalemia Hyponatremia Hemoconcentration (elevated blood osmolarity, hematocrit/hemoglobin) due to dehydration Fluid Remobilization Occurs after 24 hours Capillary leak stops See diuretic stage where edema fluid shifts from the interstitial spaces into the vascular space Blood volume increases leading to increased renal blood flow and diuresis Body weight returns to normal See Hypokalemia Phases of Burn Injury Emergent (24-48 hrs) Acute Rehabilitative Emergent Phase Immediate problem is fluid loss, edema, reduced blood flow (fluid and electrolyte shifts) Goals: 1. secure airway 2. support circulation by fluid replacement 3. keep the client comfortable with analgesics 4. prevent infection through wound care 5. maintain body temperature 6. provide emotional support Knowledge of circumstances surrounding the burn injury Obtain clients pre-burn weight (dry weight) to calculate fluid rates Calculations based on weight obtained after fluid replacement is started are not accurate because of water-induced weight gain Height is important in determining body surface area (BSA) which is used to calculate nutritional needs Know clients health history because the physiologic stress seen with a burn can make a latent disease process develop symptoms Clinical manifestation in the emergent phase Clients with major burn injuries and with inhalation injury are at risk for respiratory problems Inhalation injuries are present in 20% to 50% of the clients admitted to burn centers Assess the respiratory system by inspecting the mouth, nose, and pharynx

 Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present Change in respiratory pattern may indicate a pulmonary injury. The client may: become progressively hoarse, develop a brassy cough, drool or have difficulty swallowing, produce expiratory sounds that include audible wheezes, crowing, and stridor Upper airway edema and inhalation injury are most common in the trachea and mainstem bronchi Auscultate these areas for wheezes If wheezes disappear, this indicates impending airway obstruction and demands immediate intubation Cardiovascular will begin immediately which can include shock (Shock is a common cause of death in the emergent phase in clients with serious injuries) Obtain a baseline EKG Monitor for edema, measure central and peripheral pulses, blood pressure, capillary refill and pulse oximetry Changes in renal function are related to decreased renal blood flow Urine is usually highly concentrated and has a high specific gravity Urine output is decreased during the first 24 hours of the emergent phase Fluid resuscitation is provided at the rate needed to maintain adult urine output at 30 to 50- mL/hr. Measure BUN, creat and NA levels Sympathetic stimulation during the emergent phase causes reduced GI motility and paralytic ileus Auscultate the abdomen to assess bowel sounds which may be reduced Monitor for n/v and abdominal distention Clients with burns of 25% TBSA or who are intubated generally require a NG tube inserted to prevent aspiration and removal of gastric secretions Skin Assessment Assess the skin to determine the size and depth of burn injury The size of the injury is first estimated in comparison to the total body surface area (TBSA). For example, a burn that involves 40% of the TBSA is a 40% burn Use the rule of nines for clients whose weights are in normal proportion to their heights IV Therapy Infusion of IV fluids is needed to maintain sufficient blood volume for normal CO Clients with burns involving 15% to 20% of the TBSA require IV fluid

 Purpose is to prevent shock by maintaining adequate circulating blood fluid volume Severe burn requires large fluid loads in a short time to maintain blood flow to vital organs Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital Diuretics should not be given to increase urine output. Change the amount and rate of fluid administration. Diuretics do not increase CO; they actually decrease circulating volume and CO by pulling fluid from the circulating blood volume to enhance diuresis Common Fluids Protenate or 5% albumin in isotonic saline (1/2 given in first 8 hr; given in next 16 hr) LR (Lactate Ringer) without dextrose (1/2 given in first 8 hr; given in next 16 hr) Crystalloid (hypertonic saline) adjust to maintain urine output at 30 mL/hr Crystalloid only (lactated ringers) Nursinf Diagnosis During emergent Phase Decreased CO Deficient fluid volume r/t active fluid volume loss Ineffective Tissue perfusion Ineffective breathing pattern Acute Phase of Burn Injury Lasts until wound closure is complete Care is directed toward continued assessment and maintenance of the cardiovascular and respiratory system Pneumonia is a concern which can result in respiratory failure requiring mechanical ventilation Infection (Topical antibiotics Silvadene) Tetanus toxoid Weight daily without dressings or splints and compare to pre-burn weight A 2% loss of body weight indicates a mild deficit A 10% or greater weight loss requires modification of calorie intake Monitor for signs of infection LOCAL AND SYSTEMIC SIGNS OF INFECTION- GRAM NEGATIVE BACTERIA Pseudomonas, Proteus May led to septic shock Conversion of a partial-thickness injury to a full-thickness injury Ulceration of health skin at the burn site Erythematous, nodular lesions in uninvolved skin Excessive burn wound drainage

 Odor Sloughing of grafts Altered level of consciousness Changes in vital signs Oliguria GI dysfunction such as diarrhea, vomiting Metabolic acidosis Lab Values Na hyponatremia or Hypernatremia K Hyperkalemia or Hypokalemia WBC 10,000-20,000 Nursing Diagnosis in Acute Phase Impaired skin integrity Risk for infection Imbalanced nutrition Impaired physical mobility Disturbed body image Planning and Implementation Nonsurgical management: removal of exudates and necrotic tissue, cleaning the area, stimulating granulation and revascularization and applying dressings. Debridement may be needed Dressing the Burn Wound After burn wounds are cleaned and debrided, topical antibiotics are reapplied to prevent infection Standard wound dressings are multiple layers of gauze applied over the topical agents on the burn wound Rehabilitation Phase of Burn Injury Started at the time of admission Technically begins with wound closure and ends when the client returns to the highest possible level of functioning Provide psychosocial support Assess home environment, financial resources, medical equipment, prosthetic rehab Health teaching should include symptoms of infection, drugs regimens, f/u appointments, comfort measures to reduce pruritus Diet Initially NPO Begin oral fluids after bowel sounds return Do not give ice chips or free water lead to electrolyte imbalance High protein, high calorie Goals

 Prevent complications (contractures) Vital signs hourly Assess respiratory function Tetanus booster Anti-infective Analgesics No aspirin Strict surgical asepsis Turn q2h to prevent contractures Emotional support Debridement Done with forceps and curved scissor or through hydrotherapy (application of water for treatment) Only loose eschar removed Blisters are left alone to serve as a protector controversial Skin Graft Done during the acute phase Used for full-thickness and deep partial-thickness wounds Post care of skin graft Maintain dressing Use aseptic technique Graft should look pink if it has taken after 5 days Skeletal traction may be used to prevent contractures Elastic bandages may be applied for 6 mo to 1 year to prevent hypertrophic scarring