Burns Flashcards
1
Q
Burns are caused by:
A
- Dry Heat
- Chemicals
- Ionizing radiation
- Moist Heat
- Electricity
- Hot surfaces
2
Q
Age Related Changes
A
- Thinner skin
- Slower healing time
- Reduced inflammatory and immune responses
- Reduced thoracic and pulmonary compliance
- Pre-existing medical conditions diabetes mellitus, kidney impairment, or pulmonary impairment
3
Q
Prevention Chart 62-1
A
- Minimize sun exposure
- Advise that matches and lighters be kept out of the reach of children.
- Emphasize importance of never leaving children unattended around fire or in bathroom/bathtub.
- Educate about the installation and maintenance of smoke and carbon monoxide detectors on every level of the home and changing batteries annually on birthday.
- Recommend the development and practice of a home exit fire drill with all members of the household.
- Advocate setting the water heater temperature no higher than 48.9°C (120°F).
- Educate about the perils of smoking in bed, smoking while using home oxygen, or falling asleep while smoking.
- Caution against using flammable liquids to start fires and/or throwing flammable liquids onto an already burning fire.
- Warn of the danger of removing the radiator cap from a hot car engine
- Recommend avoidance of overhead electrical wires and underground wires when working outside.
- Advise that hot irons and curling irons be kept out of the reach of children.
- Discourage running electric cords under carpets or rugs.
- Recommend storage of flammable liquids well away from a fire source, such as a pilot light.
- Educate importance of being aware of loose clothing when cooking over a stovetop or flame.
- Recommend having a working fire extinguisher in the home and knowing how to use it.
4
Q
Severity of Burn Injury
A
- Severity determined by multiple factors:
- Age of patient
- Depth of the burn
- How much body surface is involved
- Lung involvement
- Other injuries
- Location of the burn
- Greater than 40% TBSA (total body surface area) burns are at high risk of mortality and morbidity
5
Q
First Degree - Superficial
A
- Least damage; epidermis is only part of skin that is injured
- Caused by
— Prolonged exposure to low-intensity heat (e.g.,
— Short (flash) exposure to high-intensity heat. Redness with mild edema, pain, and increased sensitivity to heat occurs as a result. - Desquamation (peeling of dead skin) occurs 2 to 3 days after burn sunburn)
6
Q
Second Degree - Partial Thickness Table 62-1
A
- Involves epidermis and portion of dermis
- Caused by scalds, flash flame
- Causes pain, hyperesthesia (extreme sensitivity in your sense of touch), sensitive to air currents
- Appears blistered, mottled red base
- Recovery in 2-3 weeks
- Hair follicles remain intact.
7
Q
Third Degree – Full Thickness Burn
A
- Involve total destruction of the epidermis, dermis, sometimes subcutaneous tissue, connective tissue, muscle
- Causes can be flame, hot liquids, electrical currents, chemical contact
- Wound color ranges widely from pale white to red, brown, or charred.
- The burned area lacks sensation because nerve fibers are damaged.
- Appears, pale, white, leathery and dry due to the destruction of microcirculation
- Edema
- Hair follicles and sweat glands are destroyed.
- Severity often deceiving because no pain in the injury area
- Patient may be unconscious or in a coma
- Shock
- Myoglobinuria
- May have Eschar
- May need grafting
- Scarring and loss of contour and function
8
Q
4th Degree - Full Thickness Burn
A
- includes fat, fascia, muscle and or bone
- Caused by prolonged exposure or high voltage electrical injury Extend into deep tissue, muscle, or bone
- Shock
- Myoglobinuria
- Charred appearance
- Amputations likely
9
Q
Classifications of burn depth from Kaplan
A
- Superficial (1st Degree) eg. sunburn
- Superficial partial-Thickness (2nd Degree) eg. Scalds from hot water
- Deep partial-thickness (2nd Degree) eg. Scalds from grease
- Full Thickness (3rd Degree) eg. Extensive contact hot objects
- Deep Thickness (4th Degree) eg. Extensive contact hot objects
— Brunner readings do not get this specific.
10
Q
Body Surface Area
A
- Different methods used to estimate TBSA = Total Body Surface Area affected
- Rule of Nines
- Lund and Browder
- Palmer Method
- Tools used to make decisions on which hospital to treat patient.
- Chart 62-2 gives criteria for referral to Burn Center
11
Q
Rule of Nines
A
As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen were burned, this would involve 55% of the body.
12
Q
Pathophysiology of Burn Injury
A
- Local and systemic problems which affect F/E, protein losses, sepsis and multiple system changes. (30% or more approx.)
- Anatomic changes – Depending on how deep, skin may not grow back Functional changes – missing protective barrier, F/E balance
— Temperature – skin maintains temperature, Vit D, Phys Identity - Pain – Most are very painful (full thickness burn destroys nerve endings)
- https://www.youtube.com/watch?v=OxPlCkTKhzY
13
Q
Pathophysiology of Burn Injury
A
- Immediately after injury generalized edema
- Hypermetabolism
- Hyperdynamic circulation
- Increased o2 glucose consumption
- Catabolism of muscle and bone
- Immune dysfunction
- Insulin resistance
- Impaired organ perfusion
14
Q
Burn s/s: system
A
- Cardiovascular
— Cardiac depression, edema, hypovolemia - Pulmonary:
— Vasoconstriction, edema - GI:
— Impaired mobility and absorption,vasoconstriction, loss of mucosal barrier function with bacterial translocation, increased pH - Kidney: vaso constriction
- other:
— Altered thermal regulation, immuno-depression, hypermetabolism
15
Q
Cardiovascular Changes
A
- Hypovolemic shock – Common cause of death in early phase in patients with serious injuries
- Volume Fluid Leak in first 24-36 hours peaking at hour 6-8
- Low CO until 18-36 hours post injury or until fluid resuscitation
Nursing Interventions
— Monitor V/S, Cardiac Rhythm especially in cases of electrical burn injuries.
— Edema
— Peripheral pulses
— Fluid Resusitation
16
Q
Fluid and Electrolyte Alterations
A
- Fluid shift: Third spacing or capillary leak syndrome, usually occurs in first 12 hr, can continue 24 to 36 hr
- Profound imbalance of fluid, electrolyte, acid-base; hyperkalemia and hyponatremia levels; hemoconcentration (decrease in plasma volume causing increase in concentration of RBC’s and other constituents)
- Fluid remobilization after 24 hr, diuretic stage begins 48 to 72 hr after injury, hyponatremia and hypokalemia
- Edema can lead a circumferential burn to compartment syndrome.
- Treatment for edema
— Elevation
— Removal of eschar - escharotomy
— Decompression of edema - Fasciotomy
17
Q
Surgical Management of Burns in Resuscitation Phase
A
Escharotomy
Fasciotomy
18
Q
Pulmonary Assessment
A
- Determine if inhalation injury
- Continuous airway assessment is a nursing priority.
- Degree of inhalation depends on source, temp, environment and toxic gas
- Assess for:
— Burns inside mouth
— Singed nasal hairs
— Black particles of carbon
— Edema of nasal septum
— Smoky smell to breath. - Give O2 and Call RRT if: hoarse, brassy cough, drooling, difficulty swallowing, audible breath sounds
19
Q
Injuries to the Respiratory System
A
- Inhalation Injury
— Upper Airway – above the glottis
— Lower Airway – Below the glottis - Carbon monoxide poisoning – leading cause of death
- Thermal injury to resp tract (upper airway edema/obstruction
— intubate - Smoke poisoning
- Pulmonary fluid overload
- External factors – tight eschar
- Facial edema
20
Q
Kidney/Urinary Assessment
A
- Changes related to cellular debris, decreased kidney blood flow
- Myoglobin released from damaged muscle, circulates to kidney
- Kidney function, BUN, serum creatinine, serum sodium levels
- Urine color, odor, presence of particles/foam
- Nursing Interventions
— Measure I/O’s
— Fluid Resuscitation to maintain output
— Assess urine color, odor and clarity
21
Q
Immunologic/Thermoregulator/GI
A
- Skin is the largest barrier to infection
- Burn injury produces cytokines that cause WBC destruction
- Loss in ability of body to regulate temperature
- Low Body temps
- Changes in GI function expected
- Decreased blood flow and sympathetic stimulation during early phase cause reduced GI motility, paralytic ileus
- GI bleeding
- Curling’s ulcer (24 hours)
22
Q
Phases of burn care:
A
Emergent/resuscitative
Acute/intermediate
Rehabilitation
23
Q
Emergent/resuscitative
- duration
- priorities
A
- Duration
— from onset of injury to completion of fluid resuscitation - Priorities
— primary survey; A,B,C,D,E,
— prevention of shock
— prevention of respiratory distress
— detection and treatment of concomitant injuries
— Wound assessment
24
Q
Acute/intermediate
- duration
- priorities
A
- Duration
— From beginning of diuresis to near completion of wound closure - Priorities
— wound care and closure
— prevention or treatment of complications, including infection
— nutritional support
25
Q
Rehabilitation
- duration
- priorities
A
- Duration
— From major wound closure to return to individuals optimal level of physical and psychosocial adjustment - Priorities
— prevention and treatment of scars and contractures
— physical, occupational, and vocational rehabilitation
— function and cosmetic reconstruction
— psychosocial counseling
26
Q
Resuscitation Phase
A
- may be referred to Emergent Phase begins at onset of injury and continues for about 24 to 48 hours, immediate evaluation, fluid resuscitation, edema and reduced blood flow assessment
- Goals include:
— secure the airway
— support circulation and organ perfusion by fluid replacement
— keep the patient comfortable with analgesics
— prevent infection through careful wound care
— maintain body temperature
— provide emotional support
27
Q
Acute Phase
A
- 36 to 48 hours after injury when fluid shift resolves and lasts until wound closure is complete.
- Goals include
— assessment of card and resp systems, GI and nutrition status, burn wound care, pain control, and psychosocial interventions.
28
Q
Rehabilitation Phase
A
begins with wound closure and ends when the patient achieves his or her highest level of functioning.
29
Q
Emergent Resuscitation/Early Phase of Burn Injury
Chart 62-4
Emergency Procedures
A
Emergency Procedures
- Extinguish the flames or remove from source
- Cool the burn
- Remove restrictive objects
- Cover the wound
- Irrigate chemical burns
30
Q
Emergent Resuscitation/Early Phase of Burn Injury
Chart 62-4
After respiratory protection:
A
- After respiratory protection:
- IV access
- Fluid resuscitation
- Baseline Vital signs include weight
- TBSA
- Labs Foley
- NG Tube
- Clean Sheets
31
Q
Fluid Resuscitation
A
- Initiated in burns greater than 20% to maintain organ perfusion
- Careful fluid resuscitation (over and under assoc. with poor outcomes)
- Central lines preferred due to large volumes of fluid
- LR used as most closely resembles human plasma
- American Burn Assoc. fluid resuscitation formula within first 24 hours
- 2 mL LR × patient’s weight in kilograms × %TBSA second-, third-, and fourth-degree burns
- Timing begins at point of injury
- One half of total calculated volume is given in the first 8 hours
- Second half of the calculated volume is given over the next 16 hours.
32
Q
Lab Assessment
A
- Fluid loss causes elevation of :
— Hemoglobin, Hematocrit, Urea Nitrogen (BUN)
— Glucose from stress response and altered uptake in injured tissues - *Carboxyhemoglobin Normal 0%-10%
— Elevated as a result of inhalation of smoke and carbon monoxide - K disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis
- NA decreased due to trapped edema fluid and lost though plasma leakage
- Protein and albumin low – exudate lost from wound
33
Q
Nutrition Management
A
- LR provides fluid and electrolytes
- For Hypermetabolism
— Increase protein by 2-4 times normal
— Increase calorie intake by 3-5 times normal up 10,000 Kilocalories - Started early in management of care
- May need feeding tube
34
Q
Management in Emergent Phase Chart Nursing Diagnosis
A
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Deficient fluid Volume
- Hypothermia
- Acute Pain
- Anxiety
- Infection
- Absence of complications
35
Q
Acute Intermediate Phase
A
- Begins about 48 to 72 hr after injury; lasts until wound closure is completed
- Care directed toward:
— Continued assessment and maintenance of CV, respiratory systems
— Continued assessment and maintenance of GI and nutritional status
— Watch for infection (sepsis)
— Burn wound care
— Pain control
— Psychosocial interventions
36
Q
Acute Phase of Burn Injury
A
- Use strict aseptic technique- Always remember Infection Prevention
- Explain all procedures.
- Reassure patients that pain will be managed effectively and give IV Opioids
- opioid analgesics and non-opioid analgesics.
- Encourage active participation in pain control measures, including nonpharmacologic interventions.
- Notify Rapid Response Team immediately if patient with an inhalation injury becomes more breathless or audible wheezes disappear.
- Coordinate with dietician for high calorie, high protein deit
- Protein supplements, enteral tube feedings, TPN may be used
37
Q
Management of Burns
A
- Airway Maintenance
- Humidified O2
- IV fluids – Needed to prevent shock then watch for Fluid overload
- Watch for HF in older adults – may need dopamine to increase CO
- Positioning and Deep Breathing to improve breathing
- Monitoring patient response to fluid therapy
- Drug therapy
- Manage Pain – opioids via IVP only
- Assess for Hyperthermia once shock resolves
38
Q
Wound Cleaning
A
- Goal is to
— Remove nonviable tissue and wound exudate
— Remove previously applied topical agents - Gentle cleaning with mild soap, water and washcloth
- Patient comfort important
- Promote exercise of extremities
- Thorough Inspection during cleaning
- Education
- Encourage family presence
- Assess for hypothermia
- Table 62-4 List of Topical Antimicrobials
- Important to alternate antimicrobial agents to reduce resistance, greater effectiveness and decrease chance of sepsis.
- Silver sulfadiazine (Silvadene)
- Silver Nitrate
- Silver Impregnated dressings
- Mafenide acetate (Sulfamylon)
39
Q
Wound Dressings
A
- Standard Wound Dressings – Layered Gauze
- Biologic Dressings
— Homografts - Xenografts - Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. If the patient’s pulse is diminished, this is a critical situation and must be addressed immediately.
40
Q
Wound Care Debridement
4 types:
A
- Removing devitalized tissue or burn eschar
- Prepares skin for grafting or wound healing
- Removes bacteria, foreign bodies, protects against sepsis
4 Types
- Natural – Occurs spontaneously – weeks to months
- Mechanical – Surgical Tools-
- Chemical – Topical enzymatic agents cause wound to debride
- Surgical – Completed early to remove devitalized tissue along with wound closure
- https://www.youtube.com/watch?v=LDJ4Tr3lkeY
41
Q
Wound Grafting
A
- Autograft – patients own skin
- Homografts or allografts- human skin
- Heterografts or xenografts – other animal
- Cultured skin - grown skin
- Artificial Skin
- Biosynthetic
- Synthetic
Wound covering
— Grafts decrease chance of infection Prevent further loss of protein, fluid and Electrolytes
— Minimize heat loss
— Earlier functional ability
— Reduce chance of contracture
— Autografts preferred (pts skin) Care of burn site and donor site important
— Homografts and Xenografts (Biologic Dressings)
42
Q
Pain Management
A
- One of the most painful types of trauma
- Exposed nerve endings
- Multiple debridement’s, surgeries, treatments
- Many causes increase pain including movement, PT and OT
- Pain is continuous even when inactive
- Pain meds include:
— Opioids
— NSAIDS
— Anxiolytics
— Anesthetic agents
— Benzodiazepines - Non Pharmacological Treatment
43
Q
Infection Prevention
A
Multi strategy approach
- Barrier techniques – PPE
- Environmental Cleaning
- Topical Antimicrobials
- IV Antibiotics antifungals
- Early wound care and closure
- Control hyperglycemia
- Management of hypermetabolic response
44
Q
Promote Physical Mobility:
A
- Breathing exercises
- Positioning for comfort
- Avoid contractures
- ROM
- Ambulation
- Compression dressings
- Understanding grief process
45
Q
Psychosocial Aspects of Care
A
- Counsel regarding change in body image
- Encourage expression of feelings
- Demonstrate acceptance of client
- Evaluate clients readiness to see scarred areas, especially facial area
- Prepare client for discharge
- Expected Outcome
— Pt uses appropriate coping strategies to deal with post burn
46
Q
Rehabilitative Phase of Burn Injury
A
- Begins with wound closure, ends when patient returns to highest possible level of functioning
- Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of pre-burn activity
- Phase may last years or even a lifetime if patient needs to adjust to permanent limitations
