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Med Surg Unit 3 NURS 241 > Burns > Flashcards

Burns Flashcards

1
Q

Causes of Burns

A
  1. Chemical
  2. Electrical
  3. Radiation
  4. Inhalation
  5. Thermal
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2
Q

What is a Chemical Burn?

A

Occurs in homes, manufacturing industries, or the result of assault.
 The severity of the injury depends on the duration of contact, concentration of the chemical, the amount of tissue exposed, and the chemical’s action
 Contact, ingestion, inhalation, or injection of acids, alkali or vesicants

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3
Q

What is Electrical Burn?

A

Tissue injury occurs when electrical energy converts to heat energy as it travels through the body
 Described as having an “iceberg effect” because the surface injury may look small, but the associated internal injuries can be significant
 Once the current penetrates the skin, causing the entry wound, it flows through the body and damages tissues until it leaves the body at the exit wound
 The longer the current is in the body, the GREATER THE DAMAGE!
 The duration of contact is increased by tetanic contractions of the stronger flexor muscles in the forearm, which can prevent the person from releasing the electrical source
 Contact with electrical source, faulty electrical wiring, or high-voltage power lines

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4
Q

What is a Radiation Burn?

A

Occurs with prolonged exposure to the sun or to sources of such like x-rays or therapeutic radiation
 Those who work in the nuclear industry are also at risk for radiation burns associated with cancer due to exposure to ionizing radiation

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5
Q

What is an Inhalation Burn?

A

 Orofacial burns can cause edema that IMPAIRS BREATHING
 Even if you believe the patient has experience a MINOR BURN, it is critical that you assess the mouth, throat and nose for signs of soot

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6
Q

What is a Thermal Burn?

A

Contact with flames (dry heat burns), hot liquids (moist heat (scald) burns) or hot objects or substances (contact burns)
 Dry Heat: caused by flame and explosions
 Moist Heat: contact with hot liquid or steam and are common in older adults
* Immersion scald injuries usually involve the legs
 Contact Burns: occurs from hot metal, tar, or grease often leading to a full thickness injury

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7
Q

Types of Burns

A
  1. Superficial
  2. Superficial Partial Thickness
  3. Deep Partial Thickness
  4. Full Thickness
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8
Q

Superficial Burn (First Degree Burn)

A
  1. Localized injury to the EPIDERMIS occurs
     The injury is NOT life-threatening
  2. Damage: Above basal layer of epidermis
  3. Appearance: Dry, Pink to Red
  4. Edema: None
  5. Blistering: None
  6. Pain: Yes
  7. Eschar: No
  8. Method of Healing: Injured epidermis peels away; reveals new epidermis
  9. Healing Time: About 1 week
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9
Q

Superficial Partial Thickness Burn (Second Degree)

A
  1. The injury extends from the epidermis into the superficial layer of the dermis
     Thin-walled, fluid-filled blisters form
     Nerve endings are exposed to air when blisters break, causing pain
     The skin loses some of its barrier function
  2. Damage: INTO the dermis
  3. Appearance: Moist, Red, Blanching, Blistering
  4. Edema: Mild to Moderate
  5. Blistering: Yes
  6. Pain: Yes
  7. Eschar: No
  8. Method of Healing: Re-epithelialization from skin adnexa
  9. Healing Time: About 2 weeks
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10
Q

Deep Partial Thickness Burn (Second Degree)

A
  1. Injury extends from the epidermis into the DEEP LAYERS of the dermis
     Damage to hair follicles and glandular tissue occurs
     Thicker-walled blistery area form that usually present as red or waxy white
     Nerve endings are exposed to air when blisters break, causing pain
     The skin loses it barrier function
     Grafting may be necessary
  2. Damage: Deeper into dermis
  3. Appearance: Less moist, Less blanching, Less painful
  4. Edema: Moderate
  5. Blistering: Rare
  6. Pain: Some
  7. Eschar: Yes, soft and dry
  8. Method of Healing: Scar deposition, contraction, limited re-epithelialization; may need grafting
  9. Healing Time: 2-6 weeks
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11
Q

Full Thickness Burn (Third Degree)

A

Injury affects every body system and organ
 Injury extends into the subcutaneous tissue layer
 Interstitial fluids result in edema
 Immediate immunologic response occurs
 Wound sepsis may occur
 Injuries are painless because of extensive nerve damage
2. Damage: Entire thickness of skin destroyed, into fat
3. Appearance: Any color (black, red, yellow, brown, white)
4. Edema: Severe
5. Blistering: No
6. Pain: No
7. Eschar: Yes, hard and inelastic
8. Method of Healing: Contraction and scar deposition; REQUIRES GRAFTING
9. Healing Time: Weeks to Months

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12
Q

Full Thickness Burn (Fourth Degree)

A
  1. Injury affects every body system and organ
     Muscle, bone and interstitial tissues suffer damage
     Interstitial fluids result in edema
     Immediate immunologic response occurs
     Wound sepsis may occur
     Injuries are painless because of extensive nerve damage
  2. Damage: Extends into muscle, tendon, bone
  3. Appearance: Black
  4. Edema: Severe
  5. Blistering: No
  6. Pain: No
  7. Eschar: Yes
  8. Method of Healing: Need specialized care; GRAFTING DOES NOT WORK
  9. Healing Time: Weeks to months, if at all
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13
Q

History Assessment

A
  1. Obtain information directly from the patient and/or ask those who witnessed the event to provide context
  2. Ask what the patient was doing when the burned occurred, the time and place where it happened, and the source and cause of injury
  3. Ask detailed questions about how the burned occurred and the events that took place from the time of injury until help arrived
  4. Obtain age, weight and height and full health history (including pre-existing medical history, alcohol or drug use and any history of any other injuries)
  5. Obtain a list of allergies, current medication and immunizations
  6. Ask if other events took place at the time of the burn, such as a fall which could indicate that other injuries may be present
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14
Q

Physical Assessment

A
  1. Superficial (first degree burn): erythema of tissue; skin blanching with pressure, possible tenderness (resembles sunburn)
  2. Superficial Partial-Thickness (second degree burn): red, blistered, highly tender skin and blanching with pressure, but no scarring
  3. Deep Partial Thickness (second degree burn): mottled appearance that may range from white to red, may appear wet or waxy; no blanching with pressure; significantly delayed or absent capillary refill time and impaired sensation; painful to pressure; blistering (rare)
  4. Full Thickness (Third- or Fourth-Degree Burns): waxy white, leathery or charred skin that does not blanch and is nonpliable to palpation; destruction of all layers of tenderness; increased risk of infection and sepsis
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15
Q

Respiratory Assessment

A
  1. Assessment of the respiratory system is MOST CRITICAL to prevent life-threatening complications for those with inhalation injuries
     Even if you think a burn to the skin is minor, inspect the mouth, nose and pharynx
     CONTINIOUS AIRWAY ASSESSMENT IS A NURSING PRIORITY
     Facial burns and singed hair, eyebrows and/or eyelashes are STRONG INDICATORS that an inhalation injury is present
     Black carbon particles in the nose, mouth, and sputum and edema of the nasal septum indicate smoke inhalation, as does a “smoky” smell to the patient’s breath
  2. A change in respiratory pattern, drooling or difficulty swallowing may indicate a pulmonary injury and impairment of gas exchange
     Listen for hoarseness, cough, wheezing and stridor
     Place the patient upright, apply oxygen and report signs immediately to health care provider
  3. Upper airway edema and inhalation injury are MOST COMMON on the trachea and mainstem bronchi, even in the appearance of what may appear to be a minor skin burn injury
     Auscultation of these areas may reveal wheezes, which indicates partial obstruction impairing gas exchange
     Patients with SEVERE inhalation injuries may have a rapid obstruction that within a short time they cannot force air through the narrowed airways. As a result, the wheezing sounds disappears. This finding indicates airway obstruction and demands immediate intubation
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16
Q

Skin Assessment

A
  1. Assess the skin to determine the extent and depth of burn injury
  2. The size of the injury is first estimated in comparison with the total body surface area
  3. Inspect the skin tissue integrity to identify injured areas and changes in color and appearance
  4. Initial size assessment is made accurately with specific assessment tools and charts
     Except electrical burns
  5. Because specific treatment is related to the depth of the burn injury, initial assessment of the skin includes estimations of burn depth
17
Q

Laboratory Assessment

A
  1. Prothrombin Time: Looking for DIC
  2. INR: Looking for DIC
  3. Hgb/Hct: Decreased if blood loss occurs
  4. Arterial Blood Gas Analysis: may show evidence of smoke inhalation, decreased alveolar function and hypoxia
  5. Urinalysis: May show myoglobinuria and hemoglobinuria
  6. COHbg: Carboxyhemoglobin Level Test: Measures level of carboxyhemoglobin in the blood
18
Q

Early Imbalance:

A
  1. Hypovolemia due to losing volume; no skin to keep blood in body
  2. Hyperkalemia due to potassium being outside of cell because cell is destroyed
  3. Hyponatremia
  4. Hypothermia due to no skin barrier to regulate temperature
  5. Edema due to fluid shift and permeability
  6. Metabolic Acidosis due to lactic acid build up and losing Bicarb
19
Q

Late Imbalance

A

After 24-36 hours
* Hypokalemia because potassium returns to intracellular spaces (leave vascular space and goes back into cells)
* Hyponatremia continues as NA is excreted in urine (patient is peeing a lot; giving lots of fluids)

20
Q

Ongoing Issue

A
  1. Hyperglycemia due to stress, acidosis, fluid shifting and especially with muscle involvement (bad for wound healing)
  2. Hypoproteinemia: Huge loss of protein with Osmosis and muscle loss
21
Q

Diagnostic Testing

A
  1. Respiratory: Chest X-ray and Pulmonary Function Testing
    > Determine inhalation injury
  2. Cardiovascular: ECG
    > Determine cardiac changes due to potassium; also looking at electrical burn damage
22
Q

Burn Phase:

A
  1. Emergent
  2. Acute
  3. Rehabilitative
23
Q

Emergent Phase (Resuscitation)

A
  1. Begins at the onset of injury and continues for about 24 to 48 hours
    o During this phase, the injury is evaluated, and priorities of care are determined based on extent and severity of burn
    o Priorities of care during the emergent phase include: (ABCs and FLUID RESUSCITATION)
     Securing the airway
     Supporting Circulation and Perfusion
     Maintaining Body Temperature
     Safety
     Keeping the patient comfortable with analgesics
     Providing emotional support
24
Q

Acute Phase (Healing)

A
  1. Begins about 36 to 48 hours after injury, when the fluid shifts resolve and lasts until wound closure is complete (Wound Care and Prevent Complications)
  2. During this phase, the nurse coordinated interprofessional care that is directed towards continued assessment and maintenance of the cardiovascular and respiratory systems, as well as towards nutrition status, burn wound care to preserve tissue integrity, pain control, mobility and psychosocial interventions
25
Q

Rehabilitative Phase (Restorative)

A
  1. Rehabilitation efforts are started at the time of admission; the technical start begins with wound closure and ends when the patient achieves his or her highest level of functioning (Physical/Psychosocial Care)
  2. The emphasis is on the psychosocial adjustment of the patient, the prevention of scars and contractures, and the resumption of pre-burn activity including resuming work, family, and social roles
    3 This phase may take years or even last a lifetime, depending on the degree and impact of burn (s)
26
Q

Extreme Version (Complications)

A
  1. Hypovolemia leading to Hypovolemic shock
  2. ARDS/Ventilator Dependent
  3. Infection and Sepsis
  4. PAIN
  5. SIADH
  6. DIC
  7. Metabolic Changes
  8. Hypothermia
  9. PTSD: Alteration in coping, body imaging
  10. Emotional Effects
27
Q

Intervention: Fluids

A
  1. USE MULTIPLE LARGE-BORE IV LINE
  2. Must maintain circulation volume for adequate CARDIAC OUTPUT
  3. First 12 hours: ECF shift= Third spacing to interstitial spaces
  4. After 24 hours, fluids return to vascular spaces
  5. PREVENT SHOCK: Large fluid loads in SHORT time to maintain organ perfusion
  6. Watch use of diuretics- will pull from circulating volume
  7. Type of Fluid dependent on Phase of Burn
     ALWAYS START WITH LR
28
Q

Intervention: Wound Care

A
  1. Medicate/Anesthetize for pain with burn wound care
     IV morphine for severe pain
     If on an ambulatory basis, use ibuprofen or acetaminophen for adequate pain control
  2. Examine SIZE and APPEARANCE with each dressing change
     Look for granulation, necrosis, or eschar
  3. Follow specific orders: various methods for wound care
     Debridement may be done by physician or by chemical/cream
     Dressing may vary; specialized wound covering
  4. May use specialty beds to reduce pressure points
  5. Ensure team follows asepsis and isolation procedures!
29
Q

Intervention: Facilitating Airway Maintenance

A
  1. Tailor interventions to your respiratory assessment
  2. For inhalation burns:
     Administer oxygen
     Keep emergency airway equipment near the bedside
30
Q

Intervention: Pain Management

A
  1. Medicate 30 mins before starting a dressing change
  2. Severe pain: IV morphine
     Teach about side effects (like constipation) and emphasize using the drug for the shortest amount of time
     Administer in small frequent amounts and be alert for possible respiratory depression
  3. Ambulatory Basis: ibuprofen or acetaminophen for adequate pain control
  4. Mannitol for treatment of oliguria in electrical burns
  5. Silver Sulfadiazine: Silver-containing agent topically to burn site
31
Q

Intervention: Infection Prevention

A
  1. Teach proper dressing technique
  2. Take prescribed oral antibiotics for the full course, even if burn begins to look or feel better
  3. For uncomplicated burns, a topical antimicrobial drug may be prescribed, to be covered with a gauze dressing
  4. Remind about the importance of strict handwashing before and after wound care
  5. Teach patient to contact provider if sign and symptoms of infection arise (increasing redness, warmth to the touch, purulent drainage, or fever)
  6. A tetanus vaccination may be administered if the patient has not had one in the past 10 years or does not recall when the last vaccine was obtained
32
Q

Intervention: Wound Healing

A
  1. Depending on the burn type, severity and location, A COMPRESSION GARMENT may be applied to prevent contractures and tight hypertrophic scars
  2. These garments also inhibit venous stasis and edema in areas with decreased lymph flow
  3. Compression dressing may be elastic wraps or specially designed, custom-fitted, elasticized clothing that provides continuous pressure
33
Q

Intervention: Nutrition

A
  1. NPO until severity of burn is established, and the HIGH-PROTEIN, HIGH-CALORIE
  2. Enteral feedings for patients unable to take food orally
  3. TPN if patient is unable to take food by mouth or enterally
  4. Control of blood glucose levels because of hypermetabolic stress response if receiving TPN
34
Q

Patient Teaching

A
  1. Instruct people to assess water temperature before bathing and showering
    > Hot water heaters should be set BELOW 120 degrees
  2. Stress the importance of NEVER adding flammable substances to an open flame
  3. Use of sunscreen agents and protective clothing to avoid sunburn
  4. Never smoke in bed and avoid smoking when drinking alcohol or taking drugs that induce sleep
  5. Keep matches and lighters out of reach of children or people who are cognitively impaired
  6. Keep clothing, bedding and other flammable objects away from space heaters
  7. Keep screens and door closed on the front of fireplaces and have chimneys swept each year
  8. Remind patient’s with home oxygen to NOT SMOKE or have open flames in a room where oxygen is in use
35
Q

Expected Outcomes:

A
  1. Free from Infection
  2. Stable or improving physical mobility
  3. Stable or improving body image
  4. Adequate nutrition
  5. Stable or improving skin integrity
  6. Stable perfusion and gas exchange
  7. Wound Care, Medication, Pain management education

Med Surg Unit 3 NURS 241 (2 decks)

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