Burn Notes Flashcards
Superficial partial-thickness burn signs & symptoms
erythema (redness) blanching on pressure (whitens with applied pressure) pain mild swelling can blister and peel after 24 hours
Superficial partial-thickness burn involved structures
epidermis
Epithelization (Skin growth) can occur
Deep partial-thickness burn signs & symptoms
blisters
severe pain due to nerve damage or death
mild to moderate edema
Deep partial-thickness burn involved structure
Epidermis and dermis
Full-thickness burn signs & symptoms
Leathery skin that can be dry or waxy You can see burst vessels Visible tendons, fat, muscles and bones No pain due to nerve death Possible skin necrosis
Full-thickness burn involved structures
Destroyed skin & local nerves
Who are the high risk factors of burns?
Children younger than 4 and adults over 65.
What are the types of burn injuries?
Thermal - most common Chemical Electrical Smoke inhalation - most deadly Cold Thermal
How do you determine the severity of burns?
Rule of Nines - initial assessment
Lund-Browder chart - more accurate
Rule of Nine: Give the parts and their percentage
Head - 9%, 4.5 each for front and back Trunk (includes chest, back, and butt) - 36%, 18 each for front and back Arm - 9%, 4.5 each for front and back Perineal - 1% Leg - 18%, 9 each for front and back
Lund-Browder: Give the parts and percentage
Face- 3.5 Back of head - 3.5 Front Neck - 1 Back of Neck - 1 Chest- 13 Back- 13 Shoulder & Upper Arm- 2 Lower Arm- 1.5 Wrist and Palm- 1.5 Perineal- 1 Butt- 2.5 each buttcheek Upper leg- 4.75 Lower leg- 3.5 Ankle and feet - 1.75
How do you prevent hypothermia for large burns?
Do not cool for more than 10 min.
Do not soak
Do not cover with ice
How do you care for a patient with burns for prehospitalization?
Ensure ABCs
Provide 100% Humidified O2
Remove clothing gently
Wash chemical burns with water for 20 min to 2 hours
Wrap burned area with clean sheet or dry blanket to prevent infection
Tissue destruction can occur for how many hours after burn exposure?
72 hours
What are the phases of burn management?
Emergent
Acute (Wound Healing)
Rehabilitative
What are the main concerns in emergent phase?
Hypovolemic shock and edema formation
Fluid & Electrolyte shifts in Emergent phase
Water, Electrolyte and proteins move into interstitial spaces due to increased capillary permeability.
Protein pressure within blood stream (Colloidal osmotic pressure) decreases.
Third spacing occurs
RBCs are depleted but high Hct is shown due to hemoconcentration
Potassium shifts first, then sodium
Hypovolemic shock signs & symptoms
Decreased BP and increased HR
What signifies the end of emergent phase?
Diuresis and urine has low specific gravity
C/M of Emergent phase
Evidence of partial or full thickness burns (pain, blister formation, etc.)
Paralytic ileus (absent bowel sounds)
Shivering
Unconsciousness or altered mental status due to hypoxia
What three major organ systems are susceptible for complications during the Emergent phase?
Cardiovascular
Respiratory
Renal
Cardiovascular complications in Emergent phase
Dysrhythmias
Hypovolemic shock
Impaired circulation - sludging (poor circulation in capillaries)
Venous thromboembolism (VTE)
Respiratory complications in Emergent phase
Pneumonia (PNA) - leading cause of death Upper Airway injury Lower Airway injury Metabolic Aphyxiation Respiratory distress Pulmonary Edema Sputum has carbon
Signs & Symptoms of Respiratory Distress
Increased agitation
Restlessness
Abnormal breathing patterns: tachypnea or bradypnea
Urinary complications in Emergent phase
Myoglobinuria
Acute Kidney Injury (AKI)
Acute Tubular Necrosis (ATN)
RBC breakdown
What is the “Iceberg effect” of electrical burns?
More damage in the skin than what is shown.
List in order of priority for Nursing management in Emergent phase.
ABC Fluid therapy Wound Care Manage pain Nutrition therapy Rehab with PT or OT
How do you manage airway?
Intubate- especially with facial and neck burn
Escharotomy of chest wall - especially with neck and chest burns
Fiberoptic bronchoscopy - 6-12 hours after injury to check lower airway
Humidified air 100% oxygen - CO posioning
High Fowlers - reposition every 2 hours
deep breathing and coughing
PEEP (positive end-expiratory pressure)
Monitor CO with SpCO2 device
Parkland Formula
It is used for fluid replacement therapy for first 24 hours.
4ml LR x wt in kg x TBSA (%body burn)
What is the application of the parkland formula?
1/2 total volume first 8 hours
1/4 total volume second 8 hours
1/4 total volume third 8 hours
How do you evaluate fluid resuscitation?
Monitor urine output hourly
Monitor MAP - MAP > 65mmgHg, systolic > 90mmHg, HR 60-100bpm.
Open Method
used for facial burns.
Topical antimicrobial agents
No dressing over wound
Multiple Dressing Changes or Closed Method
Has dressing over wound that is changed every 12 hours to 14 days.
What is a temporary skin coverage for patients with major burns?
Allograft or homograft from cadavers
What cream do they apply on dressings during wound care?
Silver Sulfadiazine cream
Why can’t patient with ear burns have pillows near their ears?
Prevent chondritis and infection.
Nursing management for ear and neck burns?
Keep rolled towel underneath the shoulders to raise head.
Why should you give pain medications IV?
Onset of action is faster.
IM injections can cause a medication pooling in the tissues, leading to a potential overdose.
Oral drugs can’t be absorbed rapidly due to paralytic ileus and GI function is slow.
What are common pain medications? When should you administer it?
Morphine & Dilaudid - drug of choice
Fentanyl, oxycodone
Around the clock, and before dressing changes.
What immunization is important for burn patients to have?
Tetanus immunization to prevent infection.
All burn patients needs it.
What is the beginning rate that of enteral feedings for burn patients?
20-40 ml/hr and will increase in the next 24-48 hours.
Hypermetabolic state
Your body is consuming 50-100% more calories in your resting state. This is true for patients with major burns (>50% TBSA).
Fluid and Electrolyte shifts in Acute Phase
Fluids and Electrolytes are going back to “normal” but still needs to be monitored.
Potassium and Sodium changes can occur.
C/M of Acute Phase
Partial-thickness burns start to form eschar and heal
Full-thickness burns needs skin graft
Normal Bowel sounds
Hyponatremia and management
occurs due to diarrhea and suctioning
Dilutional hyponatremia can occur due to too much water in system.
Offer drinks with electrolytes (juice, Gatorade, etc.)
Hypernatremia and management
occurs due to excess amounts of hypertonic fluids.
Sodium restriction may be needed during feedings.
Hypokalemia and management
Potassium is lost due to patient’s wounds, vomiting, diarrhea, suctioning, and no potassium supplements.
Give potassium supplements
Hyperkalemia and management
Occurs with renal insufficiency, adrenocortical insufficiency, and deep massive tissue injury (electrical burns).
Treat the cause.
What are some complications of the acute phase?
Infection Delirium Electrolyte imbalance Cerebral Edema Joint contractures Curling's ulcer Hyperglycemia Same cardiovascular and respiratory complications can occur
Curling’s ulcer
GI ulcer due to increased stomach acids and low blood flow.
Treatment of Curling’s ulcer
Let the patient eat ASAP Proton Pump Inhibitors Antacids H2-histamine blockers Monitor for bleeding
Wound Care
Prevent infection via cleansing and debridement
Promote skin growth or successful skin grafting
Blebs
Occurs in facial grafts
Exudate that prevents wound bed and graft from sticking together
Excision and grafting
Removal of damaged tissue and applying skin grafts
Types of skin grafts
Autograft
Cultured Epithelial Autograft (CEA)
Integra Artificial skin
Allograft (AlloDerm)
Autograft
From patient’s own skin in an unburned area using a dermatome.
Donor site care
Promote wound healing
Prevent infection
Decrease pain
Cultured Epithelial Autograft (CEA)
using patient’s own skin from biopsies to make new skin.
Integra Artificial skin
synthetic dermis good for reconstructive burn surgery
2 kinds of pain for burn patients
continuous background pain
treatment-induced pain
PT and OT management
Do exercises during dressing changes
Do passive and active ROM on all joints
Proper positioning and splinting if necessary
What type of diet is needed for burn patients?
high carbohydrate, high protein
What should you do once a patient is off a mechanical ventilator or extubated?
Get a speech pathologist to assess swallowing before giving food.
Goals of Rehabilitation phase
To allow patient to function in society
To help with functional and cosmetic postburn reconstructive surgery
C/M of Rehabilitation phase
Skin color is no longer red or pink but a lighter hue compared to surrounding tissue.
Color may not completely return for people of color
Scarring is present with discoloration and raised contours
Itching on healing areas
Flaky skin
Hypersensitivity to temperature and touch
Most common complication that can occur during Rehabilitation phase
Joint Contracture
How can you prevent joint contractures?
Proper positioning & splinting
Exercises until skin matures
Burned extremities could be wrapped with elastic bandages and gauze
Discharge teaching
Proper dressing changes
One shower daily using warm soap and water to clean wounds
When to contact burn team (infection, increased pain, etc.)
Water-based cream to help with itchiness and flaky skin
Sun protection
Keep PT and OT routines
Older patient considerations
Take longer time to heal
Increased risk for injury
High risk for complications during emergent and acute phase to occur
Thermal burn Interventions
Assess and monitor ABC’s
Assess for inhalation injury
Give 100% humidified O2 PRN
Anticipate ET tube and mechanical ventilation especially for neck and chest burns
Monitor v/s, LOC, respiratory status, O2 saturation and heart rhythm.
Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses.
Establish IV access with 2 large bore catheters.
Begin fluid replacement therapy.
Insert urinary catheter
Elevate limbs above heart
Give IV analgesia and assess effectiveness frequently
Identify and treat other injuries.
Electrical burn Assessment
Burn odor Cardiac arrest Depth and extent of wound difficult to see-Assume injury is greater than what is seen Decreased peripheral circulation in injured extremity Dysrhythmias Fracture or dislocations from force of current Impaired touch sensation Leathery, white or charred skin Location of contact points LOC Minimal or absent pain Neck or head injury if fall occurred Thermal burns if clothing ignites
Electrical burn Interventions
Remove patient from electrical source while protecting rescuer.
Assess ABCs
Provide supplemental 100% humidified O2
Monitor v/s, heart rhythm, LOC, respiratory status and O2 sat
Remove nonadherent clothing, shoes, watches, jewelries, glasses or contact lenses.
Cover burned areas with dry dressings or clean sheet
Establish IV and start fluid replacement therapy
Identify entrance and exit wounds
Obtain ABGs
Insert urine catheter
Elevate limbs above heart
Give IV analgesia and assess effectiveness frequently
Identify and treat other injuries.
Monitor for myoglobinuria and hemoglobinuria
Anticipate possible administration of NAHCO3 to alkalize urine and maintain ph.
Chemical burn Assessment
Burning Decreased muscle coordination Discoloration of injured skin Edema of surrounding tissue Localized pain Paralysis, redness, swelling of injured tissue Respiratory distress if chemical inhaled Tissue destruction continuing up to 72 hours.
Chemical burn Interventions
Assess ABC
Provide supplemental 100% humidified O2
Brush dry chemical off skin before irrigation
Remove nonadherent clothing, shoes, watches, jewelries, glasses or contact lenses.
Flush chemical from wound and surrounding area with copious amounts of saline solution or water
For chemical burn of eyes, flush from inner to outer corner of eye with water or LR
Cover burned areas with dry dressings or clean sheet
Establish IV access with 2 large bore catheters
Start fluid replacement therapy
Insert urine catheter
Elevate limbs above heart
Give IV analgesia and assess effectiveness frequently
Contact poison control center
Consider impact of identified chemical and treat accordingly
Monitor pH of eye
Inhalation injury Assessment
Altered mental status, including confusion, coma Carbonaceous sputum Cherry-red skin color (CO levels >20%) Coughing Darkened oral or nasal membranes Decreased O2 saturation Difficulty swallowing Dysrhythmias Increasing hoarseness Irritation of upper airways or burning pain in throat or chest Productive cough with black, gray or bloody sputum Rapid, shallow respirations Restlessness, anxiety Singed nasal or facial hair Smoky breath
Inhalation injury Interventions
Assess and monitor ABC’s
Assess for concurrent thermal burns
Give 100% humidified O2 PRN
Anticipate ET tube and mechanical ventilation especially for neck and chest burns
Monitor v/s, LOC, respiratory status, O2 saturation and heart rhythm.
Obtain ABGS, carboxyhemoglobin levels, and chest x-ray
Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses.
Establish IV access with 2 large bore catheters.
Begin fluid replacement therapy.
Insert urinary catheter
Elevate limbs above heart
Give IV analgesia and assess effectiveness frequently
Identify and treat other injuries.
Cover concurrent burned areas with dry dressings or clean sheet
Anticipate need for fiberoptic bronchoscopy or intubation
Ketorolac
Nonsteroidal anti-inflammatory
Relieves pain
lorezepam (Ativan)
Sedative
Reduces anxiety
Gabapentin
Adjuvant analgesics
Relieves pain
hydromorphone (Dilaudid)
Opioid
Relieves pain
Main choice for pain
esomeprazole (Omeprazole, Nexium)
GI support
Decreases stomach acid and risk for Curling’s ulcer
