Burns 3 Flashcards
describe kidney and urine function in resuscitation phase
- r/t decreased blood flow and cellular debris
- urine output is decreased (unconcentrated and high specific gravity)
- myoglobin released from damaged muscle and circulated to kidneys
how do you assess kidney function in resuscitation phase
assess kidney function by measuring urine output hourly, compare with fluid intake
what is the greatest problem r/t disruption in fluid and electrolyte balance
shock
describe hypovolemic shock in burn pts
- common cause of death in the resuscitation phase in pts with serious injuries
- decreases C.O.
what to monitor for cardiovascular assessment
-cardiac status: central and peripheral pulses, cap refill, pulse ox
describe the skin assessment of burn pt
- assess skin and determine size and depth of burn injury
- TBSA (total body surface area): compare burn to this
- important for diagnosis, prognosis, calculating fluid and drugs
- inspect tissue integrity
describe the rule of 9s
- body divided into rule of 9s
head: 4.5% anterior and 4.5% posterior
chest: 18% anterior and 18% posterior
arm: 4.5% anterior and 4.5 posterior (for each extremity)
leg: 9% anterior and 9% posterior (for each extremity)
these provide precise measurement of amount of perfusion of the injured tissue
ICG (idocyanine green)
LDI (lase doppler imaging)** most common
what is a priority nursing interventino
monitoring pts resp status
GI assessment for rescuscitation
- decreased blood flow reduced GI motility and promotes development of paralytic ileus
- bowel sounds are decreased
- pt with 25% TBSA require NG
these do NOT provide direct assessment data about the burn wound
-x ray and scans
normal hemoglobin (M and W)
M: 14-18 g/dL
W: 12-16 g/dL
normal hematocrit (M and W)
M: 42-52 %
W: 37-47 %
normal urea nitrogen
10-20 mg/dL
normal glucose
74-106 mg/dL
normal sodium
136-145 mEq/L
normal potassium
3.5 - 5.0 mEq/L
normal chloride
98-106 mEq/L
normal PaO2
80 -100 mmHg
normal paCO2
35-45 mmHg
normal COHb
0-10%
normal total protein
6.4 - 8.3 g/dL
normal albumin
3.5 - 5 g/dL
what are the problems if the burn is > 25 % TBSA
1) potential for decreased oxygenation
2) potential for shock
3) pain (acute and chronic)
4) potential for ARDS
when does upper airway edema become pronounced
8-12 hrs after fluid resuscitation begins
what needs to be monitored profusely in resuscitation and what can improve it
gas exchange
positioning and deep breathing can improve breathing and gas exchange
what may be needed if long term intubation is expected
tracheotomy
describe titration
adjustment of IV fluid rate on basis of urine output plus serum electrolyte values
how is hypovolemia prevented
- IV fluid and drug therapy to restore perfusion (fluid resuscitation)
- large bore central venous catheter, peripheral lines can be useful
- monitor pt response to determine blood perfusion and adequacy of resuscitation
how to determine if blood perfusion and resuscitaiton treatment is adequate
urine output (noninvasive assessment) want hourly urine output of 30 mL/hr
