9.2 Nursing Process for Burns Flashcards
Stages
Emergent/Resuscitative Phase
- Onset of injury until completion of fluid resuscitation
Acute/Intermediate Phase
- Beginning of diuresis until wound closure
Rehabilitation Phase
- From wound closure until return to optimal physical/psychological adjustment
Burn Priorities
- ABC’s
- 100% humidified oxygen for mild pulmonary injuries (encouraged to cough)
- For severe cases bronchial suctioning to remove secretions and bronchodilators and mucolytics.
- AIRWAY IS INCREDIBLY IMPORTANT BECAUSE AIRWAYS CAN CLOSE QUICK FROM EDEMA AND TOXIC EFFETS OF SMOKE
Emergent/Resuscitative Phase
EMS Team
- Eliminates burn source
- Supports vital functions
- Transports
Acute Stage
Emergency Team (Emergency Room)
- Fluid resuscitation
- Ventilator management
Burn Team (Burn/ICU Unit)
- Fluid management
- Ventilation
- Surgery
- Hydrotherapy
- Nutrition
- Physical Therapy
- Wound care
- Medication
- Psychosocial support
Healthcare Team (Med-Surg)
- Nutrition
- Wound care
- Physical therapy
- Medication
- Psychosocial support
Rehabilitation Phase
Social Services
- ADL’s
- Vocational training
- Psychosocial Support
- Physical therapy
- Community resources
- Follow-Up
On-The-Scene Care
- Prevent injury
- Extinguish fire, irrigate chemical burns, cool burn down
- ABCs
- Start oxygen and IV
- Remove restrictive objects and cover the wound
- Assess all body systems
- Treat patient with falls/electrical injuries for potential cervical spine injury
ER Care
- Fluid resuscitation and foley catheter
- NG tube for 20-25% TBSA burns
- Patient is stabilized (ABGs, VS, Carboxyhemoglobin)
- ECG for patients with electrical burns
- ONLY IV MEDICATIONS SHOULD BE ADMINISTERED (PAIN)
Math
Parkland
- 4mL x kg x TBSA%
- 50% of total in first 8 hours, 25% for each 8 hours after
- SECOND 24 HOURS USE CRYSTALLOID WITH 5% DEXTROSE TITRATED TO URINARY OUTPUT
ABLS
- 2-4 mL x kg x TBSA%
Nursing Management
- ABCs
- VS
- Hemodynamic status
- Monitor fluid volume deficit
- Assess extent of burn
- TETANUS PROPHYLAXIS
Pulmonary Support
- Inhalation injury is a frequent cause of death in burn patients (due to smoke inhalation and cutaneous burns)
- Inhalation injury predisposes patients to pneumonia (which increases mortality rate to 60%) - Children and elderly are especially at risk.
Goals
- Improve oxygenation
- Decrease interstitial edema and airway occlusion
- Humidified oxygen in Fowler Position
- Severe upper airway obstructions may require ET tube
- High fowler position, coughing, deep breathing, chest physiotherapy, reposition, frequent tracheal suction, incentive spirometry and bronchoscopic removal of debris.
Racemic Epinephrine
- Aerosolized topical vasoconstrictor, bronchodilator, and secretion bond breaker
Vasoconstrict - reduces sub/mucosal edema
- Also used to treat post-extubation stridor
- Given every 2-4 hours as long as HR does not excessively increase
Medications Given for Burns
- Nebulized racemic epinephrine for airway edema and obstruction. (water added as a diluent helps break bonds of secretions)
- Secondary bronchodilator to reduce muscle spasms of bronchioles
Carbon Monoxide Poisoning
- Carbon monoxide combines with hemoglobin to displace oxygen and forms carboxyhemoglobin.
- Carbon monoxide has 200x greater affinity to hemoglobin than oxygen (if too much it will cause hypoxia)
Symptoms
- Anxiety
- N/V
- Weakness
- Headache
- RED SKIN
Treatment
- 100% humidified oxygen
- Intubation if needed
Carboxyhemoglobin
COHb
- Ranges
Nonsmokers - Up to 3%
Smokers - 10-15%
Fluid and Electrotype Shifts
Manifestations
- Dehydration
- Reduced blood volume
- Decreased urine Output
- Metabolic Acidosis
- Hyperkalemia (from cells releasing potassium)
- Sodium traps in edema fluid and shifts into cells as potassium is released (hyponatremia)
Fluid and Electrotype Shifts
- Edema forms in 4 hours from superficial burns
- Edema takes up to 18 hours to form for deeper burns
- Caused by increased perfusion to injured area and increased capillary permeability in that area (reflects the amount of microvascular and lymphatic damage to tissue)
Burns greater than 30%
- Inflammatory mediators stimulate local/systemic reactions causing extensive shift of fluids (electrolytes/proteins) to surrounding interstitiam.
TREATMENT FOR EDEMA
- Elevation of extremity
Reabsorption of Edema
- Reabsorption begins at 4 hours post-injury and completes 4 days after
- Fluid resuscitation is important for tissue perfusion but can increase edema causing ischemia and necrosis (in burned and non-burned tissue)
Immediately After Burn INjury
- Hyperkalemia from massive cell destruction
- Hypokalemia later with fluid shifts
- Hyponatremia may occur due to plasma loss or in the first week due to water shifts into interstitial areas.
- Anemia can also occur from destroyed RBC’s however hematocrit may still be elevated due to plasma loss
- Thrombocytopenia and increased prothrombin times can also occur
Complications of Burns
- Acute respiratory failure
- Distributive shock
- AKI
- Compartment syndrome
- Paralytic Ileus
- Curling Ulcer (reduced plasma volume leads to ischemia and cell necrosis of gastric mucosa)
Escharotomy
- Also used to treat edema (instead of elevation of extremity)
- It is removal of eschar (devitalized tissue)
- Surgical incision through eschar
Fasciotomy
- Surgical incision through fascia to decompress edema and restore tissue perfusion
Burn Treatment
- Circumferential burns to an arm or leg can mimic compartment syndrome (due to edema surrounding the entire extremity)
- Remove rings, watches, jeweler
- Elevation and range of motion for injured extremity.
- Escharotomy at bed side
- Narcotics/Benzodiazepines for comfort
HOURLY
- Assess skin color, capillary refill, peripheral pulses
- Assess HR, BP, and UO to monitor fluid resuscitation
ADULT URINARY OUTPUT
- At least 30 mL/hr
- 0.5 mL/kh/hr
Second Phase: Acute
- 48-72 hours after injury
- Focus is infection prevention, wound care, pain management, modulation of hypermetabolic state, early mobility
Infection
- Most common cause of death in burn patients after 7 days
- Immune system is compromised from burn
- CATHETER MUST BE HANDLED WITH STERILE TECHNIQUE
- STERILE GLOVES FOR DRESSING REMOVAL AND WOUND EXPOSURE
- MONITOR SEPTIC SHOCK
Fluid/Electrolyte Shift
- Fluid re-enters vascular space
- Hemodilution
- Increased urinary output
- Hyponatremia (due to loss of sodium from diuresis and dilution of vascular space from fluid re-entering vascular space)
- Potential hypokalemia when potassium goes back into cells.
- Metabolic acidosis
Third Stage: Rehabilitation
Focus
- Wound healing
- Psychosocial support
- Self-Image
- Lifestyle
- Restoring maximal function
Interventions
- High protein diet
- Physical therapy
- Preventing scars/contractures
- Psychologic rehabilitation
Cleansing of burn
- Hydrotherapy
- Topical agents
- Clean with water, chlorhexidine or NS with providone iodine (Betadine) with each dressing change
- Culture eschar and granulation 3 times a week to identify contamination
Silver Sulfadiazine
- Topical drug of choice on admission
- May cause transient leukopenia (requires CBC monitoring)
- Discontinue if WBC drops below 3000 and restart once WBC is normal again
Mafenide Acetate Cream
- Drug of choice for increased colony count (broad-spectrum bacteriostatic)
- Discomfort with this cream is common
Debridement of Wound
Mechanical
- Wet-dry or Wet-Wet dressing changes
Enzymatic Debridement
- Apply proteolytic substances to burn wound to shorten time of eschar separation
Surgical Debridement
- Allows for minimal loss of viable tissue
Dressing Changes and Grafts
- Grafts locations are picked to areas of similar color, texture, and thickness
Sheet Graft
- Skin applied to surgical excised area
Mesh Graft
- Applied to burn site
- Dressing is used to immobilize grafted area
Fish skin (tilapia) and pig skin are usually used for grafts.
- Tilapia is a great cheap way that can speed healing process
Physiologic Support
- Weekly family meetings
- Work with psychiatric liaison nurse
- Hallucinations, confusion, and combativeness are common
Nutritional Support
- Greater nutritional need due to stress, hypermetabolism, and wound healing
- Goal is to promote nitrogen balance
- Enteral route is preferred
Jejunal feedings
- lowers risk of aspiration in patients with poor appetite, weakness, and other problems.
Home Instructions
- Mental health
- Skin and wound care
- Exercise/Activity
- Nutrition
- Pain management
- Thermoregulation and clothing
- Sexual issues
Toxic Epidermal Necrolysis Syndrome
- TENS
- Superficial exfoliated dermatitis (can be caused by adverse reaction to medication, staph, or viral infection
Necrotizing Fascilitis
- Rapid and progressive inflammatory infection of soft tissue
Cold Injuries
- Localized frostbite or systemic lowering of body core temperature with hypothermia
