Burns Flashcards
Damage to skin integrity from an energy source
Burn
Degree of superficial burns
1st degree
Characteristics of 1st degree superficial burns
Affects epidermis, skin warm to touch, pink and painful, blanching, no scarring, heals in a few days
Degree of partial thickness burns
2nd degree
Characteristics of 2nd degree partial thickness burns
Affects epidermis and dermis, blisters (intact or ruptured), shiny, moist, painful, blanching, heals 2-6 weeks
Degree of full thickness burns
3rd degree
Characteristics of 3rd degree full thickness burns
Affects all layers (epidermis, dermis, hypodermis), white/blackened, charred leathery skin, may look black/yellow/red/wet, limited to no pain (nerve fibers destroyed), skin will not heal (need skin grafting), eschar, hypertrophic scars
Layers of the skin
Epidermis, dermis, hypodermis (subcutaneous tissue)
Burn caused by superficial heat source such as liquid, steam, fire
Thermal
Burn caused by toxic substances such as bleach, gasoline, paint thinner
Chemical
Burns caused by UV radiation (sunburns) and cancer treatment
Radiation
Burn caused by inhaling smoke which can cause flame injury or carbon monoxide poisoning
Inhalation
Burn caused when an object rubs off the skin such as road rash, scrapes, carpet burn
Friction
Burn caused by overexposure of the skin to cold
Cold (frostbite)
Burn by which an electrical current passes through the body, causing damage within
Electric
Inhalation injury happens most in a
Closed area
Signs of inhalation injury
Hair singed around the face/neck/torso, trouble talking (hoarse voice), soot in nose/mouth, bright red lips, confusion, anxiety
Signs of carbon monoxide poisoning
Hypoxia, neuro changes, drowsiness, dizziness, nausea, headache, cherry red skin and lips
Treatment for carbon monoxide poisoning
100% O2 with NRB mask until COhb level is below 10%
Burns to the neck, face (nose/mouth), chest and torso can lead to
Respiratory complications
Burns to the hands, eyes, feet, and joints can cause
Disability
Burns to the eyes, ears, and perineum (or anywhere considered a portal or entry/exit) places the patient at high risk for
Infection
Full thickness/circumferential burns on the extremities and torso can increase the risk for
Compartment syndrome
Intervention for circumferential burns
Elevate extremities above heart level to decrease edema
Phases of burn management
“EAR”: Emergent, Acute, Rehabilitative
The onset of injury to the restoration of capillary permeability (24-48 hrs after burn)
Emergent phase
Pathophysiology of emergent phase of burns
Increased capillary permeability causing fluid to shift from intravascular (blood) to interstitial (tissues) space (sodium and albumin follows). This causes fluid volume deficit in the intravascular space and edema (third-spacing)
Vital signs associated with emergent phase of burns
Increased HR, decreased BP, CO, and UO (similar to hypovolemic shock)
Labs associated with emergent phase of burns
Elevated potassium, hematocrit (hemoconcentration), and BUN/creatinine, decreased WBCs and sodium
Nursing interventions during emergent phase of burns
Establish IV access (preferably 2), fluids (LR, crystalloids), parkland formula, albumin, Foley catheter (monitor UOP), elevated extremities above heart level to decrease edema, stop burning process and stabilize, patient, infection prevention
Stabilization of capillary permeability to wound closure (48-72 hours after burn and until wounds have healed)
Acute phase
Pathophysiology of acute phase of burn
Capillary permeability restored, diuresis (increased UOP), excess fluid shifts from interstitial space back to intravascular space
Acute phase of burns goals
Prevent infection (antibiotics), proper nutrition (increased calories, protein, vit C for healing), pain relief, wound care (premedicate, debridement or grafting)
Renal nursing considerations during acute phase of burn
Diuresis is happening —> Foley catheter to monitor UOP
GI nursing considerations during acute phase of burn
Risk for paralytic ileus and curlings ulcer (d/t FVD and decreased perfusion to stomach), H2 histamine blocking agents to reduce HCL and decrease chance of ulcers, monitor bowel sounds, NG tube for suctioning
Burn is healed and patient is functioning mentally and physically (could be weeks - years)
Rehabilitative phase
Goals of rehabilitative phase of burn
Psychosocial, ADLs, PT, OT, cosmetic corrections
Formula used to calculate the total volume of fluids (mL) that a patient needs 24 hours after experiencing a 2nd or 3rd degree burn
Parkland formula
Parkland formula
4 mL x TBSA (%) x body weight (kg) = total mL of fluid needed
After using parkland formula to calculate fluid needed, give the first half of the solution in the first ___ hrs and the second half of the solution over the next ___ hours
8; 16
What kind of burns carry a risk for inhalation injury?
Chemical, thermal, and electrical (electrical can also lead to cardiac arrest)
Burn severity depends on several factors including
Depth (partial/full thickness/degree), TBSA %, age, medical hx, location
Populations at risk for burn complications
Elderly, children, HF, DM
Top layer of skin that protects us from environment and prevents infection
Epidermis
Layer of skin that contains blood vessels, nerve endings, sweat/oil glands, and cells that create new skin
Dermis
Patients who have endured burns that damage the dermis may be unable to
Make new skin cells (skin grafts may be needed to promote healing)
Layer of skin composed of subcutaneous tissue containing fatty tissue, veins, arteries, and nerves
Hypodermis
Function of hypodermis
Insulation, regulation of body temperature
Patients with full-thickness burns, which cause damage all the way through the hypodermis, will have problems with
Regulating body temperature (keep room between 85-100 degrees for these patients!)
Interventions for first degree burns
Cool compress (cool saline soak), analgesics
Types of 2nd degree partial thickness burns
Superficial partial thickness, deep partial thickness
Complications of 2nd degree burns
Infection, scarring, contractures
Permanent tightening of the muscles, tendons, skin, and surrounding tissues causing joints to shorten and stiffen
Contractures
Interventions for 2nd degree burns
Cool compress, elevation, professional care
Complications of third degree burns
High risk for infection, shock, respiratory distress, organ failure, extensive scarring, contractures, functional impairment
Interventions for 3rd degree burns
Fluid resuscitation (LR or NS 0.9%), wound care, early intubation recommended in patients showing signs of upper airway injury
Oral pain medications should be administered at least ___ min before dressing changes or ___ min if given IV
30; 15
Degree of deep full thickness burn
4th degree
Characteristics of 4th degree burn
Affects all layers of skin and extends into muscle, bone, ligaments; loss of sensation, appears black and charred w/ eschar
4th degree burn intervention
Skin grafting
Interventions for partial thickness burns
Fluid resuscitation, cover wounds w/ antibiotic ointment (non-adherent dressings), cleanse other areas w/ mild soap and gently scrubbing to reduce infection risk
Treatment of choice for partial thickness burns
Hydrocolloid dressings (moisture promotes healing)
Characteristics of superficial partial thickness burns
Red, painful, may blister, heals within a few weeks with minimal scarring
Characteristics of deep partial thickness burns
Red, mottled appearance with blistering, painful, may require more time to heal and scarring can be significant
Skin grafts must be
Sterile
Third degree burn priority
Assessment of fluid level and swelling
Mechanical ventilator settings for patients with severe burns and respiratory failure
Slightly higher respiratory rates (16-20 breaths/min) and smaller tidal volumes (7-8 mL/kg); high-frequency flow interruption ventilation
_________ ventilator may be preferred after smoke injury
Oscillating
Patients with elevated COhb levels and a pH <7.4 should be treated with
Hyperbaric oxygenation
Emergent phase of burn risks
Hypovolemic shock, respiratory distress, compartment syndrome
S/S of hypovolemic shock
Weak, thready pulses, decreased CO and BP, increased HR
Acid-base imbalance associated with acute phase of burn
Potential for metabolic acidosis d/t accumulation of lactic acid and metabolic byproducts
Why is increased caloric intake very important for burn patients?
Burns cause the body to adopt a hypermetabolic state to maintain body heat as a result of burn injury and tissue damage
Diet during acute phase of burns
High protein and fats (central line lipids may be used to supplement metabolic demands)
Caloric intake formula for adults
(25 x body weight [kg]) + (40 x TBSA%)
Caloric intake formula for children
(60 x body weight [kg]) + (35 x TBSA%)
S/S of paralytic ileus
Decreased bowel sounds, lime green vomit
Paralytic ileus interventions
NPO, NGT, TPN once bowel sounds return, high calorie/protein/carb for healing
Holes in the GI tract that develop after a person experiences great physical stress
Curlings ulcer
S/S of curlings ulcer
Gnawing pain, N/V, blood
Curlings ulcer interventions
May require NGT, colostomy
Burns <20% TBSA treatment
Combination of oral and IV fluids
Burns >20% TBSA treatment
IV fluid resuscitation (using parkland formula) due to GI ileus
Moderate burn victims should have at least ___ large-bore IV line through _________ skin
1; unburned
Severe burn victims should have at least ___ IV lines and venous catheters may be placed through _____ skin or via _________
2; burned; venous cutdown
When considerable fluid resuscitation or cardiopulmonary disease is present, use a
Central venous line
In patients with massive burns, respiratory injury, elderly patients with severe burns, or cardiac disease, monitor fluid volume with a
Pulmonary artery catheter (swan-ganz)
Albumin administration during acute phase of burn
5% albumin at 0.5 mL/kg/% TBSA
Medication used to restore renal and splanchnic blood flow
Low-dose dopamine
In patients with major burn injuries requiring fluid resuscitation, insert _____ for initial evacuation of fluid and air from the stomach and feeding access
NGT
Adequate resuscitation is evidenced by
Normal sensorium, stable vital signs, normal UOP
UOP indication adequate resuscitation in children younger than 2 years
1 mL/lb/hr
UOP indicative of adequate resuscitation in older children
0.5/lb/hr
UOP indicative of adequate resuscitation in adults
> /= 30-40 mL/hr
Referring to the parkland formula, the first 8 hours is
From the time of the burn injury
Method that uses the patient’s palm to measure body surface area burned
Palmer method (palm of patient is about 1% of the BSA)
Rule of nines entire head and neck percentage
9% (anterior and posterior each 4.5%)
Rule of nines entire arm percentage
9% (anterior and posterior each 4.5%)
Rule of nines entire leg percentage
18% (anterior and posterior each 9%)
Rule of nines anterior trunk percentage
18%
Rule of nines posterior trunk percentage
18%
Rule of nines genitalia percentage
1%
Layers involved with first degree frostbite
Epidermis
Layer involved with second degree frostbite
Epidermis and dermis
Layers involved with third degree frostbite
Hypodermis
Layers involved with fourth degree frostbite
Skin, muscles, tendons, and bones
S/S of first degree frostbite
Erythema and edema
S/S of second degree frostbite
Hard edema and clear blisters
S/S of third degree frostbite
Hemorrhagic bullae, pale grey extremity
S/S of fourth degree frostbite
Insensate, black/grey
Rewarming effects of first degree frostbite
Minimal pain with rewarming
Rewarming effects of second degree frostbite
Mild to moderate pain with rewarming
Rewarming effects of third degree frostbite
Severe pain with rewarming
Rewarming effects of fourth degree frostbite
Painless during rewarming
Guidelines for rewarming frostbite
Gentle, gradual rewarming using body heat or the warmth of another person’s body
Burn treatment
Cool water, cover the area (clean and dry), remove clothing, wrap fingers with individual dressings so they don’t adhere, non-adherent hydrocolloid dressing, tetanus immunization
Burn treatments to avoid
Ice, creams, antibiotic ointments to open skin. Do not remove anything adhering to skin
Assessment of fluid resuscitation in emergent phase (first 24 hrs)
Urine output >30, SBP > 90, HR < 120
Only IV pain meds during _________ phase of burn
Emergent
inhalation injury treatment
100% O2 with NRB mask until COHgb falls below 15%
Calculation used to calculate the total body surface area percentage of the body that is burned
Rule of nines 
Interventions for acute phase of burn
Antibiotics, increase calorie intake, pain management, intubation, if respiratory complications 
Topical antibiotics for burn injuries
Silver sulfadiazine and mafenide acetate (mafenide acetate penetrates eschar)
