Burns Flashcards
__ hampers the ability to shiver
small muscle
infants < 6 months old rely on ___ temperature controls
metabolic temp controls
temperature regulation for burns
- monitor core temperature
- external protection ie blankets, warm room
first degree burn
- Involves the epidermal layer only
- Self-replacing 3-6 days after skin sloughs off
- Skin intact; No blisters; erythema; blanches; Desquamation within 1 week of injury
mild pain for several days
second degree burn (partial thickness)
- Extends into dermal layer
Self-healing with scarring in approx. 14-21 days - Wet appearance; shiny skin, weepy; intact and partially open blisters; wound blanches; sensitive to temperature, air, and touch
deep 2nd (almost full thickness)
- Deep 2nd burns resemble full-thickness but structures such as sweat glands and hair follicles are intact
Self-healing with significant scarring in > 21 days
third degree (full-thickness)
- Extends to the subcutaneous layer destroying nerve endings, sweat glands, and hair follicles
- Periphery of wound has 1st or 2nd degree characteristics
Color varies (velvet red, white, black, brown)
Thrombosed vessels can be seen
Dry leathery appearance
Degree of pain is dependent on depth (appears with healing)
fourth degree (deep full-thickness)
- Injures underlying structures including muscle, fascia, and bone with exposure of ligaments, tendons, and bone
- Color varies with charring in deepest areas
Impaired ROM
Dull dry appearance
Insensitive to pain
minor burn
Partial thickness <10%
Full thickness <2%
treat outpatient prn
moderate burn
Partial thickness 10-20%
Full thickness 3-10%
Hot liquids
treat in hospital with burn center expertise
Topical treatments
Autografting may be required
major burn
Partial thickness >20%
Full thickness >10%
Burns involving face, eyes, ears, hands, feet, and perineum
Electrical burns, flame burns, inhalation injuries, pre-existing conditions
treat in specialized burn center
- Surgical excision and grafting
Amputation if no circulation to area
key points of moderate and major burns
- Most dramatic fluid shift in first 8-12 hrs.
- Fluid replacement is calculated from burn injury time not ER arrival
- Hypotonic IVF=high risk of hyponatremia, cerebral edema and seizures
- Increases in cyanosis, deep tissue pain, cap refill and decreased pulses with a circumferential burn=immediate MD call
- Elevate burned extremities
- Frequent monitoring and linen changes
nursing assessment: history
brief: inhalation injury
detailed: if non-life threatening
A thorough health history is important. It can help determine the seriousness of the injury. Depending on the severity of the burns, it may not be possible to get all of the data at once.
nursing assessment: detailed history
Description of incident (Date, time, cause)
r/o smoke inhalation or associated fall
Document treatment received thus far
Child’s recent health status
allergies
Current meds
Recent or chronic illness
Immunization history (esp. most recent tetanus)
Evaluate for abuse vs. accidental injury
physical assessment: primary survey
- Airway- is it patent? Maintainable?
- inhalation injury suspicion
- Skin color
- Respiratory-effort? Symmetry? Breath sounds?
- Cardiovascular- pulse strength? Perfusion? Heart rate? Edema? (grade)
physical assessment: secondary survey
Determine burn depth
Estimate TBSA (rapid estimation with chart or child’s hand)
Any other traumatic injuries? (cervical, internal)
- Perform head to toe exam to rule out associated injuries
- Knowing the mechanism of injury helps predict the type of associated trauma
- Do not be overwhelmed by the appearance of the burn
Suspect inhalation injury if:
- Burns around mouth, nose, or eyes
- Black colored sputum
- Hoarseness or stridor
pediatric airway anatomy
Relatively small airway
Less edema is needed to develop obstruction
- Larynx more anterior than in adult
- Glottis more angulated and more anterior
- Narrowest point is cricoid, not glottis
- Insert NGT for decompression which will help to eliminate swallowed air
breathing assessment
Normal use of abdominal muscles when breathing
Ensure bilateral breath sounds
Obtain CXR for tube placement
Secure tubes
care of burn patient: introduction
- ABC’s first
- Proper wound management critical in all phases of care
- Survival and functional outcome both depend on successful burn wound healing
care of burn patient: circulation
Initiate fluid resuscitation immediately
Establish early IV access:
- Percutaneous Cutdown
Femoral IO
prehospital/during primary triage at hospital:
- 5 years old and younger: use LR @ 125ml/hr.
- 6 – 14 years old: use LR @ 250ml/hr.
- Fluid for child <10kg: use D5LR
care of burn patient: disability
Assess level of consciousness
Hypoglycemia
Hypoxia
care of burn patient: expose, examine and environmental control
Remove all clothing including diaper
Assess for associated or pre-existing injuries
Cover with clean, dry linens
Conserve body heat
secondary survey: history
Events leading to injury
Past medical history
Immunization history
Allergies
Consider potential for abuse
secondary survey: calculate TBSA burn
Bigger head Front and Back totals
Smaller legs
Palmer method
(Infant hand – 1%)
secondary survey: fluid resuscitation
½ of total in the 1st 8 hours post injury
The other 1/2 over the next 16 hours
fluid resuscitation formular
children > 14 yr or > 40kg:
2mL/kg x patients weight in kg x TBSA, divide by 2 (run based on burn time)
children < 14 yr or < 40kg:
3mL/kg x patients weight in kg x TBSA, divide by 2 (run based on burn time)
electrical burns:
4mL/kg x patients weight in kg x TBSA, divide by 2 (run based on burn time)
fluid resuscitation formulas are ____. the nurse should ___ to maintain ____.
Fluid resuscitation formulas are ESTIMATES only!!
- Titrate IVF ↑ or ↓ by 1/3 to maintain U/O of 1ml/kg/hr.
escharotomy
Circumferential extremity or torso burns
Rarely done prior to transfer
Consult with the burn center
pain management of burns can reduce:
Sleep deprivation
Anxiety
tantrums
Pruritus
Post-traumatic stress
Regression
Contractures (from scars and disuse)
Graft loss (movement)
pain management of burns
Narcotics-morphine (IV or PO)
Anesthetics-propofol or ketamine
Antihistamines-diphenhydramine
Relaxation
Distraction
Medical play
Guided imagery
Family participation
child abuse
Pattern not compatible with history given
Story changes
Younger sibling is blamed for injury
Caregiver absent at time of injury
Delay in seeking treatment
Child appears passive
Other injuries
transfer criteria
Partial and Full-thickness burns to:
- face
- hands
- feet
- genitalia
- perineum
Inhalation injury
Chemical injury
Electrical injury
average hot water heater setting
140°
boiling water temperature
212°
temperature of cooking oil when frying
350-450°
flash point of cooking oils temperature
500-700°
temperature for burn injury in 10 sec
130°
burn injury in 5 seconds
140°
temperature for instantaneous full thickness burn
160°
prevention of burns
Stop drop and roll
Plug outlets
Water heater temperature
Back burner cooking
Cabinet locks
No smoking
How not to start a fire…..
fire escape plan
- working smoke detectors
- two ways out
- practice at least 1x/month
- have a meeting place
- count heads
broselow tape is used if
use if age or weight is unknown to detect TBSA
rule of nines
Rule of nines in 2nd and 3rd degree burns
Calculate percent of each area burned and not the entire area
Note: If one surface of an upper extremity is burned = 4 ½ percent TBSA rather than 9% as indicated on the lower extremities.
rule of nines: infant
patients palmar surface (hand and fingers) TBSA %
1% TBSA
oliguria
- Usually due to inadequate resuscitation
- Associated with elevation of SVR and reduction of cardiac output
- Diuretics are contraindicated
- Requires increased hourly fluid administration
hourly urine output
- large sized pre-teens and adolescents: 0.5mL/kg/hr (30-50mL/hr)
- infants and children: 1mL/kg/hr
If expected UOP increased/decreased for 2 consecutive hours:
- Decrease / increase fluid infusion by 1/3
monitoring resuscitation
Assess mental status frequently
Anxiety and restlessness may reflect hypoxia
Urinary output most reliable guide
- Indwelling bladder catheter
- Dependent upon normal renal function
limited glycogen stores when under age __
1 year old
- monitor blood glucose
pediatric patients are more susceptible to (fluid ___)
fluid overload
resuscitation and LR
- Mimics intravascular fluid
- Treats hypovolemia
- Replaces intracellular sodium deficits
- For moderate and severe burns
- Infuse via large bore IV, Central line, or IO route
