Burn Med surg Flashcards
1
Q
allograft or homograft
A
human skin obtained from cadaver
2
Q
autograft
A
graft that uses clients own skin; graft that uses the patient’s own skin
-postage stamp sized specimen; cultured in flasks for 2-3 weeks to form large sheets.
3
Q
closed method
A
burn wound is covered
4
Q
epithelialization
A
regrowth of skin
5
Q
escharotomy
A
an incision used to relieve pressure.
6
Q
eschar
A
hard,leathery crust of dehydrated skin
7
Q
full-thickness graft
A
graft that includes the epidermis, dermis, and subcutaneous tissue; used when the wound is fairly small or involves the face, hands, neck.
8
Q
heterograft
A
graft obtained from animals
9
Q
open method
A
a burn that is left uncovered.
10
Q
slit graft
A
graft that stretches a small piece of skin to cover a large area
11
Q
split thickness graft
A
technique in which the clients epidermis and thin layer of dermis is harvested.
12
Q
Most burns are assessed in what way
A
depth,severity, and for zones
13
Q
if a burn victim has been burned around the face or neck or has inhaled smoke steam or flames she should watch closely for
A
resp. difficulty.
14
Q
immediately after a serious burn, body fluids
A
shift from the plasma to the interstitial places
15
Q
a nurse comes upon the scene of a car accident in which a victim has experienced a burned arm
A
pour cool water over the burned area.
16
Q
a client is receiving wet-dry dressing changes over a burn area. before the procedure, the nurse should
A
administer an analgesic
17
Q
a client has skin grafting
A
minimize movement to prevent graft disruption
18
Q
why is it difficult to determine depths of burns
A
there are various levels of injury in the same burn
19
Q
after inital checks of airway, breath, and circulation. what is the primary focus of the burn victim
A
fluid reassociation and R/T hypovolemic shock
20
Q
why do many clients who are burned receive total parental nutrition
A
to many kcals to consume
adynamic ileus- cant have TF
cant eat
21
Q
“rule of nines”
A
is a quick method of estimating how much of the clients skin surface is involved. another quick method is to compare clients palm with the size of the burn wound. its 1% of a persons TBSA
22
Q
the zone of coagulation
A
which is at the center of the injury, is the area, where the injury is the most severe and usually the deepest.
23
Q
zone of stasis
A
the area of intermediate burn injury. it is here that blood vessels are damaged but the tissue has potential to survive. If circulation is secondarily impaired. However injured tissue in the zone of stasis can convert to zone of coagulation
24
Q
zone of hyperemia
A
the area of least injury, where the epidermis and dermis is only minimally damaged bc of the early appearance of the burn injury can change the estimate of burn depth may be revised in the first 24-72hr
25
Superficial
first degree
26
superficial partial thickness and deep partial thickness
second degree
27
full thickness
third and fourth degree.
28
3500 die from burns and 40000 of the one million are burns that cause them to be hospitalied
know
29
partial or fullthickness burn greater than 10% TBSA
know
30
autograph is the only permanent one
know
31
inf decreases the blood flow to tissues slowing the growth of repair
know
32
three to one mesh
they create a mesh pattern and it allows the skin to be able to be stretched 3xs as large
33
if the body is unsupported the skin will heal how it is left.
know
34
electricity is the most severe bc it can be very deep. the heat is greater in entry than exit (in between is where it is damaged most)
know
35
the immediate initial cause of cell damage is heat
know
36
the severity of the burn is related to
1. the temp of the heat source.
2. duration of contact
3. thickness of tissue exposed to heat soure
4. the location of the burn.
37
burns in perineum is at risk for increased inf fro organisms in the stool
know
38
burns on face,neck,or chest have the potential to impair ventilation
know
39
burns involving the hands or major joints can affect dexterity and mobility.
know
40
when a burn occurs there are localized effects within the burn tissue tht are compounded by the inflammatory process, neuroendocrine changes, shift in fluids and electrolytes, and complication from cellular, chemical, and concurrent injuries
know
41
serious burns can cause various neuroendocrine changes within the 1st 24 hrs.
know
42
adrenocorticotropic hormone and antidiuretic hormone are released in response to stress and hypovolemia. when the adrenal cortex is stimulated it releases glucocorticoids which cause hyperglycemia and aldosterone, a mineralcorticoid that causes sodium retention
know
their fluid
43
adh can be released from posterior pituitary bc of the stressful situation.
know
44
they dont give glucose first bc theyre usually hyperglycemic
know
45
aldosterone increases sodium absorption bc its a mineralcorticoid
know
46
third spacing
accumulation of fluids where theres usually not much or any-sometimes toward burn area,
immediately after a serious burn, body fluids shift from the plasma to the interstitial spaces.
47
the client enters a hypermetabolic state and requires 100% o2 humidified and nutrition to compensate accelerated tissue catabolism
know
48
curlings ulcers
gastric ulcers- can result in death; gastric ulcers as a result of increased histamine that increases gastric activity.
49
sunburn is superficial
know
50
fullthickness third degree
epidermis, dermis, subcutaneous tissue
| red,white,tan,brown,or black; leathery,covering (eschar); painless.
51
superficial first degree
epidermis and part of the dermis
| painful with pink or red edema, but subsides quickly;no scarring.
52
superficial partial thickness second degree
epidermis and dermis; hair follicles intact
| mottled pink to red, painful, blistered or exuding fluid, blanches with pressure
53
deep partial thickness second degree
deep layer of the dermis with damage to sweat and sebaceous
| variable color from patchy red to white wet or waxy dry, does not blanch with pressure, sensitive to pressure only
54
fullthickness fourth degree
epidermis,dermis, subcutaneous tissue, may include fat, fascia,muscle and bone
55
Rule of nines.....
- quick initial method of estimating how much of the patient's skin surface is injured
anterior face/neck/head.....4.5%
posterior head/neck..............4.5%
anterior arm...............................4.5%
posterior arm.............................4.5%
anterior torso.............................18%
posterior torso..........................18%
genitalia........................................1%
anterior leg..................................9%
posterior leg................................9%
56
hypovolemia
low volume of extracellular fluid
57
hyperkalemia
excessive amount of Potassium in the blood
58
fluid resuscitation
a fluid replacement regimen, calculated from the time of the burn injury....with crystalloid and colloid solutions
- goal is to restore intravascular volume, prevent tissue & cell ischemia and maintain vital organ function
- guaged by urinary output of 0.3-0.5 mL/kg/hour via Foley
- low dose infusion of dopamine may be necessary to ensure renal perfusion
* ****glucose solution NEVER given first; trauma causes cortisol to be released, already hyperglycemic
59
zenograft/heterograft
graft obtained from animals
- bovine/cow, porcine/pig
- used temporarily...they get rejected, removed and replaced
60
Jobst pressure dressing/garment
garments made of elasticized cloth or plastic, applied over a skin graft area
61
9% it total head and neck
know
62
anterior surface of head and neck
4.5%
63
18% for a total leg
know
64
9% total arm
4 1/2 for anterior or posterior
65
neck down to ischeal tuberosity
36% for total torso. if just anterior 18 %
66
S&S of extensive burns
low BP, tachycardia, tachypnea, oliguria, restlessness-monitor I&O every 1 hr
67
acute renal failure, metabolic acidosis can occur
know for extensive burns etc
68
major or referral burn can cause hypothermia and arrhythmia or further tissue damage
dont put silvadine on major burn bc it keeps heat in
69
signs of resp heat or smoke inhalation
sore throat, singed nasal hair, eye brows, eye brows, hoarsness, black sputum, soot around nose or mouth, stridor
70
O2 100% humidified
know
71
Fluid resuscitation:
| Brooke- lactated ringers, second 24 hr, colloid (plasma,albumin dextran), 5% glucose water
parkland-lactated ringers, saline, colloid, 5% glucose water
72
shock is possible within first 24-48 hrs.
most common cause of death
73
Burn tx
ventilator, smoke inhalation so suction PRN, fluid resuscitation GOAL 50 ML of urine output. Half of fluid vol given first 8hr, remaining half in next 16 hr. dopamine to keep BP up, NPO, endotracheal tube, trache kit incase, labs:CBC, HBG, albumin, chemistry panels, GFR, ABG, iv analgesics, morphine can be given for pain or apprehension, worried about depressed resp-assess rr. less than 12 you wont give.
74
burn tx
valuim for pain or apprehension, narcan just incase, affect sensorium so side rails up, antibiotics
75
most common microbes
staph aureus, psudomonas originosa, candida albicans, reverse isolation.
76
wound management
admin pain prior to tx, skin grafts,open exposure method, reverse iso. gown and gloves(sterile if touch pt) warm humidified room,
77
open exposure method (wounds debrided qd)
topical tx but no dressing not on face or perineal area.
78
bed cradle
keeps linens from touching skin
79
partial thickness hard crust forms at 2-3 days
2-3 weeks to heal completely. can be loosened with hydrotherapy, debridement, NS and saline water to bathe, hydrate skin, hubard bath
80
full thickness (eschar)
can constrict the area, prob with circulation, check pulse in that arm or wrist and may need eschirotomy to help circulation.
81
closed method- PREFERRED
put antimicrobia, wrapped with sterile gauze, non adherant keeping stuff out of it. 4x4 gauze that has vasaline on it (wont stick) and something absorbant. prevent bacteria contact with wound. changed qd
82
antimicrobials
to discourage growth of pathogens or control inf
sterile technique- MAJOR-silvadene (sulfa drug)- bacteriocidal, watch bilirubin; sulfamyelon mathenine acitate (sulfa drug) common SE it burns when applied, PH level acidosis; MAJOR silver nitrate solution- keep dressing wet; betadine broad spectrum (iodine allergy(
83
^
dont use iodine in open skin area. (sodium and potassium level) Geramycin (aminogycosides) ;;Furesin if allergic to sulfa- yellow gold cream. Acticote, aquacil ag to absorb and has silver in it. better than silvadene.
84
^
systemic antibiotics penicillin G, antifungal fungizine
85
Burn meds
topical app of meds to prevent or tx inf. Most common silvadene or sulfamyelon. SE HUrt, burn, itch, allergic reaxction. caution sulfa drugs. dont use with collagenase or tripsin
86
ASEPTIC technique, careful I&O keep area covered
with creme or sterile dressing
87
surgical management
debridement then skin graft (deep partial fullthickness esp) ,hydrotherapy,
88
if they dont do debridement hypertrophic scar tissue will happen and can cause contractures
REASON FOR DEBRIDENT
| decrease inf potential, fluid loss by evaporaion, decrease scar, increase recovery, increase healing
89
1. autograft is number one. theyll use buttocks or thigh-general anesthesia-permanent solution
know
90
why wouldnt autograft or another graft not attach
inf, bleeding, movement.
91
pedicle graft
pull skin up and makes a flap to retain blood supply.
92
disadvantages of autograph
additional pain, skin doesmt look same, pigment not the same, can get inf. wounds are delayed, hospital for longer.
93
graft site-handle with care-bed cradle sometimes
| donor site
never move graft site dressing. after graft care:biobrane applied to lower extremitty partial thickness burn.
94
problems
| hyponatremia, hyperkalemia, hypocalcemia,decreased protein, hct increased.
more rbc, cardiac output decreased.
95
criteria for 'MAJOR BURNS'
- partial or full-thickness burn greater than 10% TBSA
- burns that involve face, hands, feet, genitalia, perineum, majot joints
- full-thickness burn in any age group
- electrical burns, including lightening injury
- chemical burns
- inhalation injury
- burn injury with a preexisting medical disorder that could complicate management, prolong recovery, or affect mortality
- burns accompanied by trauma, in which the burn poses the greatest risk of morbidity or mortality
- burned children in hospitals without qualified personnel or equipment for the care of children
- burn injury for those who will require social, emotional, or rehabilitative intervention
96
how are burns classified?
SUPERFICIAL/1st degree...painful, no edema, redness, blanches with pressure; heals in less than5 days
SUPERFICIAL/DEEP-PARTIAL-THICKNESS/2nd degree....blistered, moist, painful; heals 14 days to more than 3 weeks
FULL-THICKNESS/3rd & 4th degree....dry, discolored, no pain; skin grafts necessary
97
TPN
Total Parenteral Nutrition....hypertonic parenteral solution consisting of nutrients designed to meet nearly all the caloric and nutritional needs of patients who are severely malnourished or cannot consume food or liquids for a long time
98
what are the 'Zones of a burn injury'?
ZONE OF COAGULATION: at the center of the injury; deepest, most severe injury
ZONE OF STASIS: area of intermediate burn; blood vessela are damaged, but tissue has potential to survive; circulation is secondarily impaired....can convert to zone of coagulation
ZONE OF HYPEREMIA: area of least injury; epidermis and dermis are minimally damaged
***early appearance of a burn can change; depth can be revised in first 24-72 hours***
99
characteristics of a 1st degree burn...
DEPTH: epidermis and part of dermis
| painful with pink or red edema, but subsides quickly; no scarring
100
characteristics of a 2nd degree burn...
-mottled pink to red, painful, blistered or exuding fluid, blanches with pressure
-variable color from patchy red to white, wet or waxy dry, does not blanch with pressure, sensitive to pressure only
DEPTH: epidermis and dermis, hair follicles intact; deep layer of the dermis with damage to seat and sebaceous glands
101
charcteristics of a 3rd degree burn.....
-red, white, tan, brown, or black; leathery covering/eschar; painlless
DEPTH: epidermis, dermis, subcutaneous tissue
102
characteristics of a 4th degree burn...
black, depressed, painless, scarring
| DEPTH: epidermis, dermis, subcutaneous tissue; may include fat, faschia, muscle, and bone
103
complications that can occur for a pt with serious burns
- various neuroendocrine changes
- edema
- fluid shifts
- electrolyte deficits
- loss of extracellular proteins...albumin
- anemia develops, the heat destroys erythrocytes
- hemoconcentration, when plasma is lost or trapped
- sluggish blood flow causes inadequate nutrition to healthy cells and organs
- hypotension happens
- acute renal failure
- prone to gastric ulcers
- hypovolemia
- hyperkalemia
104
Nursing Management of a pt with a serious burn......PRIORITIZED
- ABC's
- administer prescribed pain analgesics
- wounds cleansed
- calculate fluid replacement requirements
- monitor for signs of shock
- encourage adequate nutrition and provide supplements as ordered
105
who is at the highest risk for acquiring burn injuries?
....children and adults over the age of 60
106
what is the most common cause of thermal burns in older adults?
....scalding and home fires
107
a burn is...
a traumatic injury to the skin and underlying tissues.
108
what type of burns are characteristically the most severe?
electrical burns, because they are so deep
| ***they affect the CNS...must be on heart monitor to watch rhythms
109
`what causes burns?
- heat
- chemicals
- electricity
110
the severity of a burn is related to ....
1. the temperature of the heat source
2. the duration of contact
3. the thickness of the tissue exposed to the heat source
111
burns in the perineal area..
at risk for infection from organisms in stool
112
burns of the face, neck, or chest have the potential.....
| -to impair ventilation
burns involving the hands or major joints....
| -can eventually affect dexterity and mobility
113
purposes of a skin substitute or graft are to....
- lessen the potential for infection
- minimize fluid loss by evaporation
- diminish pain
- promote regeneration of tissue
- reduce scarring
- prevent loss of function
114
S/S of heat or smoke inhalation injury...
- sore throat
- singed nasal hairs, eyebrows, eyelashes
- hoarseness
- carbon in sputum
- soot around mouth and nose
- shortness of breath
- stridor
115
if blood pressure is stable, what's the nest best way to assess the patient's response to treatment?
-urine output
a disadvantage of surgical debridement is.....
| -bleeding
116
healing a wound without the use of a skin graft, or skin substitute results in....
the proliferation of granulation tissue.....contains fibroblast, which creates hypertrophic scars that contract and pull the edges of the wound together, causing an uneven appearance in the healed tissue, as well as contractures
117
what regenerates epidermis tissue?
| -keratinocytes
* **what major topical medications are used on burn wounds?
- silver-sulfadiazine/Silvadene
- mafenide acetate/Sulfamylon
- silver nitrate
118
bloodwork ordered
- CBC
- ABG
- BUN, creatanin
- protein/albumin
- electrolytes/chem panel
- BMP: basic metabolic panel, 7
- CMP: complete metabolic panel, 21
119
OPEN METHOD
- method has been virtually abandoned since the use of topical antimicrobials
- if used, client placed in isolation
- used sterile linens, bed cradle, warm humidified room
- reduces labor-intensive care
- causes less pain during wound care
- facilitates inspection
- decreases expense
- allows for epithelialization
CLOSED METHOD
- current PREFERRED method
- maintains moist wound; uses nonadherent & absorbent dressings
- promotes maintenance of body temperature
- decreases cross-contamination of wound
- provides wound debridement during dressing removal
- keeps skin folds separated
- reduces pain during position changes
120
pain/antianxiety meds a burn pt may receive, their route and why that route...
- morphine sulfate, drug of choice, as high as 50 mg/hour, IV
- naloxane/Narcan given for respiratory depression
121
Phases of care for a burn patient.....from injury to convalescence
INITIAL 1st AID.....prevent further injury; cool the burn with cool H2O; take to hospital
EMERGENT PHASE: from the scene to the hospital; O2 may be administered for inhalation burns; IV fluid therapy begun en route
ACUTE CARE PHASE: assess the extent of burn injury, as well as other injuries; maintain ventilation; bronchoscopy may be performed to assess internal airway; warmed, humidified O2 given; trach tube avaiable if needed; mechanical vent available; blood samples drawn, fluid resuscitation, IV analgesics given for pain/anxiety; tetnus shot given
WOUND MANAGEMENT: clothing removed; body hair near burn removed; burns are cleaned to remove debris; topical antimicrobial meds applied. OPEN or CLOSED method
SURGICAL MANAGEMENT: debridement; skin grafting, skin substitutes
REHABILITATIVE PHASE: helping the patient return to an optimal level of functioning
122
what complications can occur with hypovolemic shock, if interventions are not put into place?
- hypotension
- tachycardia
- oliguria
- anuria
- renal failure, caused by myoglobin and hemoglobin are transported to the kidneys
123
S/S of hypovolemic shock
- weakness
- fatigue
- fainting, dizziness
- dehydration, thirst
- nausea, vomiting
- tachycardia
- mental confusion
- pallor
- sleepiness
* **beds typically used for burn patients....
- circular bed
- air-fluidized bed
- low-air-loss bed
124
what nutritional interventions are used for the burn pt that is said to be in a 'HYPERMETABOLIC state?
- caloric intake is increased to 4000-5000 cal/day
- protein needs are typically 2-2.5 g/kg, especially if burns are more than 10% of TBSA
- fluid needs increase
- supplements of vitamins C,A, Zinc, plus a multivitamin are commonly used
- if they can't consume the amount of calories needed orally, they willl need to get them through nasogastic or nasoduodenal tube feedings
125
what can cause SHOCK for a burn pt?
- intravascular volume depletion
- depressed cardiac output
- low pulmonary artery occlusion pressures
- elevated systemic vascular resistance
126
* **hydrotherapy
| - uses Hubbard Tank....to loosen eschar tissue....bathing, electrolyte solution, normal saline, PAINFUL
* **stridor
| - high-pitched, harsh sound during respiration, indicative of airway obstruction
127
* **split-thickness graft
- technique in which the client's epidermis and a thin layer of dermis is harvested
- usually obtained from the buttocks or thighs
* **slit graft
- a graft that stretches a small piece of skin to cover a large area
- for extensive burns/ donor sites limited
- passes through machine that slits it
128
* **hyperbaric oxygen treatment
| - administration of 100% O2 at 3 times greater than atmospheric pressure in a speciallt designed chamber
* **Why should a pt receive TPN?
- if a patient has been severly burned on an area of their body that hinders them from eating; face, throat, etc
- depending on the extent of the patient's burns, they will not feel up to eating, let alone eating the amount of food that is required
129
TBSA is...
Total
Body
Surface
Area
130
Most burns are assessed in what way?
- for depth
- for zones
- by severity
131
If a burn victim has been burned about the face or neck or has inhaled smoke, steam, or flames, she should be watched closely for?
-respiratory difficulty
132
Immediately after a serious burn, body fluids:
-shift from the plasma to the interstitial spaces
133
A nurse comes upon the scene of a car accident in which a victim has experienced a burned arm. Which is the best emergency care to give this person?
-pour cool water over the burned areas.
134
A client is receiving wet-dry dressing changes over a burn area. Before the procedure, the nurse should?
-administer an analgesic
135
A client has skin grafting. What is included in the plan of care for this client?
-minimizing movement to prevent graft disruption
136
Why is it difficult to determine depths of burns?
-there are various levels of injury in the same burn.
137
After initial checks of airway, breath, and circulation, what is the primary focus in the care of the burn victim?
- fluid restriction
| - R/T hypovolemic shock
138
Why do many clients who are burned receive total parental nutrition?
- too many Kcals to consume
- adynamic ileus
- can't have TF
- can't eat
139
A nurse stops to give first aid to a burn victim running from the home that is on fire. the nurse rolls the victim on the ground to smother the flames. The chest and neck of the victim are burned. What is the priority for the nurse?
monitor the victim for repository distress
140
In the emergency department, it is determined that a burn victim has deep partial and full thickness burns over 35% of the upper body. During the nursing assessment of the burn injury what characteristics will the nurse use to identify the initial appearance of the full thickness burn?
white and leathery
141
the treatment plan for a burn victim includes using the open method of burn wound management. What is the most appropriate for the nurse to monitor when caring for a client treated by the open method?
1. infection
142
A burn wound periodically is debrided using hydrotherapy. What nursing action is essential shortly before each debridement?
administer a prescribed analgesic
143
Patient needs to wear the pressure garment for at least 23 hours a day.
know
144
Burn depth is determined by?
- assessing color
- characteristics of the skin
- and sensation in the area of the injury
145
Thermal injuries cause the protein in cells to coagulate
know
146
Neutrophils consume available oxygen at the wound site, contributing to tissue hypoxia.
know
147
Baciquent (good for facial burns)
Bactroban (effective against methicillin resistant S. aureous)
