Burns

Question 1

factors associated with burn injury/death

Answer 1

Careless smoking, alcohol/drug intoxication
Older adults- ignition of clothing when cooking or smoking.
National Institute of Burn Medicine notes that 75% of burns are caused by our own action.
Toddlers/older adults from scalds.
Match play in school age child
Electrical injury in adolescent male.
Cigarette smoking in adults
Industrial settings- largest number of burn injuries are among electricians and chemical workers.

Question 2

goals r/t human burns

Answer 2

Prevention- advocate for legislation for work place safety.
Life-saving measures for severely burned.
Prevention of disability and disfigurement.
Rehabilitation of patient through reconstructive surgery and rehabilitation programs.

Question 3

patient’s with burn injuries

Answer 3

Statistics:
a. Incidence in US has decreased in last 20 yrs.
Now 4.2/10,000. 45,000 hospitalized/year.
b. 4,500 fire and burn deaths per year. Is
decreased by 60%.
c. Is 6th leading cause of accidental death.
d. Highest risk for older adult. Most common
burn is caused by scalds.

Question 4

etiology of burn injury

Answer 4

Caused by:
	Dry heat flame
	Moist heat flame (scald)
	Contact with a hot surface
	Chemicals
	Electricity
	Ionizing radiation

Question 5

dry heat (flame)

Answer 5

Caused by open flame as in house fire and explosion.
Ignited clothing accounts for most injuries.
Explosions result in flash burn injuries because there is a brief exposure to a high temperature.

Question 6

moist heat (scalds)

Answer 6

Caused by contact with a hot liquid or hot steam.
Scald most common burn injury in toddlers and older adults.
Hot liquid spills usually burn upper frontal surfaces of the body.
Immersion scalds involve lower part of body.

Question 7

dry and moist heat burns

Answer 7

Dry heat and moist heat burns are considered to be thermal burns.
Direct exposure to source of heat causes cellular destruction that can result in injury to vascular, boney, muscular and nervous tissue.
Priority treatment:
a. Extinguish flame- stop, drop & roll.
b. Steam / Hot Liquid- consult with fire department. Remove smoldering clothing and metal objects.

Question 8

contact burns

Answer 8

Hot metal, tar, and grease can cause full-thickness burns when they contact the skin.
A body part touching an iron or space heater is an example of a hot metal injury. Also, in industry exposure to molten metals.
Tar and asphalt temperatures can be over 400 degrees so they can cause serious deep injuries within seconds when in contact with skin.
Hot grease injuries are associated with cooking and are usually deep.

Question 9

chemical burn injury

Answer 9

Occur in the home, in industry, and as a result of deliberate assault.
Tissue injury occurs when chemicals come in direct contact with the skin. Epithelial tissue is ingested by the chemical.
Severity depends on the duration of contact, the concentration of the chemical, the amount of tissue exposed, and the action of the chemical.

Question 10

chemical burn (continued)

Answer 10

Alkalis found in oven cleansers, fertilizers, drain cleaners and heavy industrial cleaners damage tissue by causing it to liquefy (liquefication necrosis) and proteins are denatured. Allows for deeper spread of chemical and more severe burns.
Acids found in bathroom cleansers, rust removers, chemicals for swimming pools and industrial drain cleaners damage tissue by coagulating cells and proteins ( coagulation necrosis). Tends to limit depth of damage.

Question 11

chemical burns (continued)

Answer 11

Organic compounds found in many chemical disinfectants and in gasoline cause damage by fat solvent action. Also, once absorbed can produce toxic effects on the kidneys and liver.
Priority treatment:
a. Brush off any dry chemicals present on skin
clothing. Remove clothing.
b. Ascertain chemical causing burn and
consult Poison Control Center. Do not
attempt to neutralize chemical unless it is
positively identified and the appropriate neutralizing
agent is available.

Question 12

electrical burn injury

Answer 12

An electrical injury happens when electrical current enters body. Called “Grand Masquerader” because small surface injury may be associated with severe internal injuries.
Divided into high and low voltage with high being over 1000 volts.
Tissue injury results from electrical energy being converted into heat energy.
Extent of injury depends on type of current, pathway of flow, local tissue resistance, and duration of contact.
Skin is most resistant organ. If skin resistance is overcome, the body acts as a conductor and current flows throughout the involved body part.
Bone has high resistance because of its density. Current flows along surface of the bone and the heat generated damages adjacent muscle. Deep muscle injury may be present even when superficial tissue seem ok.

Question 13

electrical burns (continued)

Answer 13

The longer the electricity is in contact, the greater the damage. Duration is increased by tetanic contractions of flexor muscles preventing person from dropping source.
Generally there is entry and exit wounds. Entrance site usually well defined and round, whereas exit site is explosive and surrounded by charred tissue.
External burn injuries can occur when the current jumps or arcs between two surfaces. Injury is severe and deep.
True electrical injury occurs when there is direct contact with the electrical source. Internal damage results as electricity travelson the inside to the outside. Organs in the path of the current may become ischemic or necrotic. More than 90% of injuries to extremities result in gangrene development and amputation.

Question 14

electrical burns continued

Answer 14

Alternating current as in homes, produces tetanic muscle contraction. This can inhibit respiratory effort and cause arrest.
Direct current as in a lightening bolt exposes the body to very high voltage for an instant. Usually there is entry and exit wounds.
Flash-over effect (unique to lightening) may save a person’s life since the current travels over the moist surface of the skin rather than internally.

Question 15

priority treatment of electrical burn injury

Answer 15

Disconnect electrical source.
Smother any flames that are present.
Initiate CPR. Get ECG if possible.
Consult electrical specialist

Question 16

thermal burns

Answer 16

dry heat flame & moist heat flame (scald)

Question 17

radiation burns

Answer 17

Occurs with exposure to large doses of radioactive material.
Most common injury is from therapeutic radiation. Injury is usually minor and there is rarely extensive skin damage.
Injuries are more serious in industry when person is exposed to radioactive isotopes. The extent of the injury depends on the amount & type of energy deposited over time.
Severity is determined by type of radiation, distance from the source, absorbed dose, and depth of penetration into body.

Question 18

radiation burn treatment

Answer 18

Shield skin appropriately for solar uv rays.
Limit exposure time to radioactive agents like Xrays.
If exposed to radioactive agent:
a. Remove patient from the source.
b. If exposed to radiation from an unsealed
source, remove clothing with tongs or lead
protected gloves.
c. If radioactive particles are on the skin, send to
nearest decontamination center for bathing or
showering.

Question 19

old classification of burn death

Answer 19

First Degree- Damage limited to epidermis. Erythema appears and patient has pain.
Second Degree- Damage to epidermis and dermis. Blisters and mild to moderate edema develops. Patient has pain.
Third Degree- All dermal elements are effected. There will be white, brown, red, or black leathery tissue with thrombosed vessels, although no blisters appear. No pain.
Fourth Degree- Damage extends to subcutaneous tissue, to the muscle and bone.

Question 20

superficial burn

Answer 20

Damage only to top layer of skin. See peeling of dead skin.
Color is pink to red with mild edema. There is pain.
No blisters. Healing time 3 to 5 days. No graft is needed.
Examples would be a sunburn or flash burn.

Question 21

superficial partial thickness burn

Answer 21

Entire epidermis and variable portions of the dermis are destroyed.
Color is pink to red with mild to moderate edema. Blisters are present and there is pain. Nerve endings may be exposed.
Healing time is about 2 weeks.
Examples are scalds, flames, brief contact with hot surface.

Question 22

deep partial thickness burn

Answer 22

Extends into deeper layers of the dermis. There are fewer healthy cells that remain. Blood vessels are patent. If blood supply degreases, ischemia can result and burn can convert to full thickness.
Color is red to dry white with moderate edema. Blisters are rare and some eschar may be present. There is pain. Healing time is 2 to 6 weeks and if prolonged may need graft. There may be scars.
Will blanche with pressure. Examples are scalds, flames, prolonged contact with hot surface, grease or chemicals.

Question 23

full thickness burn

Answer 23

Reaches through entire dermis and sometimes into subcutaneous fat. There is no residual epidermal cells to repopulate. Cannot heal on it’s own. Will need grafting. No blisters.
Color black, waxy white, brown, yellow, or red with severe edema. Eschar and thrombosed vessels are present. Nerves may be totally destroyed so may not have pain. Tissue is leathery and does not blanche under pressure.
Healing time weeks to months. Need grafts.
Examples are scalds, flames and prolonged contact with hot objects, tar, grease, chemicals and electricity.

Question 24

deep full thickness burn

Answer 24

Extends further than subcutaneous Tissue like to fascia and tissues. Color is black with edema and pain is absent. There are no blisters. Healing time is weeks to months.
Can be damage to muscles, bone and tendons.
Need early excision and grafting. Amputation may be needed if an extremity is involved.

Question 25

burn zones

Answer 25

Burns have characteristic skin surface appearance that resembles a bull’s eye with most severe burn located in the center and lesser located along the periphery.
May be 1-2-3 concentric 3 dimensional zones corresponding to depth of burn.

Question 26

minor burns

Answer 26

Deep partial thickness less than 15% TBSA.
Full thickness less than 2% TBSA.
No burns of eyes, ears, face, hands, feet or perineum.
No electrical or inhalation injuries. No other complicated injuries.
No patient over 60yrs and no chronic cardiopulmonary and endocrine disorders.
Patient receives care at ER. Burn Center not needed.

Question 27

moderate burN

Answer 27

Deep partial thickness not more than 25%.
Full thickness not More than 10%.
No burns to eyes, ears, face, hands, feet, and perineum.
No electrical or inhalation injuries.
No chronic cardiopulmonary and endocrine disorder.
Patient under 60yrs.
Patient receives care at specialized center or Burn Center

Question 28

major burns

Answer 28

Partial thickness greater than 25% TBSA.
Full thickness greater than 10% TBSA.
Any burn involving eyes, ears, face, hands, feet, and perineum.
Electrical and inhalation and complicated injuries. Patients 60 and older with chronic conditions.
Patients receive care at nearest ER and are transferred to Burn Center.

Question 29

older adult considerations for burns

Answer 29

At risk for all degrees and severity for injury. Sensory awareness may be decreased with aging.
May have cognitive impairment and start a fire by leaving cooking unattended. May delay treatment so increases risk for infection.
Have thinner skin, decreased mobility and reaction time. Burn will be more extensive.
Immune response is decreased so healing time is slower and there is increased risk of infection and sepsis. May have pre-existing conditions.

Question 30

cultural considerations for burns

Answer 30

For African Americans a sickle cell preparation may be appropriate if sickle cell status is unknown.
Trauma can trigger a sickle cell crisis in those with the disease or the trait

Question 31

pathophysiology of burns

Answer 31

Tissue destruction results from coagulation & protein denaturation or from ionization of cellular contents when in contact with heat source.
Early tissue damage may occur at temp. of 104 degrees F. (40 degrees C.). Irreversible damage to dermis occurs at temp. of 158 degrees F.
Skin & mucosa of upper airways are most common sites of tissue destruction.
Deep tissues including viscera can be damaged by electrical burns or through prolonged contact with burning agent.

Question 32

first effect of a burn

Answer 32

First effect a burn has is to produce a dilatation of the capillaries and small vessels in the area of the burn.
This increases capillary permeability.
There is a fluid shift from intravascular space to the interstitial area in burns over 20 to 30%. Period is known as third spacing or capillary leaking syndrome.
In burns over 30%, capillary leaking is not confined to burn area alone. There is edema throughout the body.

Question 33

fluid leak of a burn

Answer 33

Generally, fluid leak occurs over first 24 to 48 hours post burn, peaking by 12 hours.
Patient will need fluid resuscitation during this period.
Plasma, proteins, and electrolytes are lost from vascular space but RBCs usually remain in vascular compartment which results in increased blood viscosity, hematocrit, and hemoglobin in early hours post burn.

Question 34

fluid loss of a burn

Answer 34

Fluid loss results in decreased fluid volume in vascular system and there is a fall in blood pressure and cardiac output. Causes burn shock.
Response of sympathetic nervous system is an increase in peripheral resistance and an increased heart rate.

Question 35

when capillaries regain integrity with burns

Answer 35

As capillaries begin to regain their integrity (48 to 72 hours post burn) fluid returns to vascular space and patient moves into Acute Stage of burn care.
Vascular compartment volume increases. Extra strain is placed on the heart and kidneys. If heart and renal system are adequate, urinary output is greatly increased.
Diuresis continues for several days to two weeks with a loss in body weight.
During this period patient is at risk for fluid overload and may require cardiotonic drugs and diuretics to support circulatory function and prevent CHF.
Monitor B/P, pulse, central venous pressure, pulmonary artery wedge pressure and hourly urinary output.

Question 36

fluid electrolyte and blood needs of burns

Answer 36

In the Emergent Phase there is hyperkalemia, hyponatremia and metabolic acidosis.
Aldosterone is released causing reabsorption of sodium and water in the renal tubules.
Retained sodium accumulates in the interstitial tissue with fluid. Sodium pump fails (normally pumps NA out of cell and K into cells. Potassium is released into intravascular space.
Also have evaporative fluid loss through the burn wound. May reach 3 to 5 liters per 24 hours.

Question 37

acute phase of burns

Answer 37

During Acute Phase (Fluid Remobilization) blood volume increases as fluid shifts from interstitial space to intravascular space. Leads to increased blood flow to kidneys and increased urinary output.
Hyponatremia continues because of increased renal sodium excretion and loss of NA from wounds.
Hypokalemia results from potassium moving back into cells and being excreted in urine output.

Question 38

emergent phase of burns

Answer 38

Metabolic acidosis remains a possibility because of loss of sodium bicarbonate in the urine .
Hemoconcentration is seen in the Emergent Phase due to vascular dehydration. This increases blood viscosity, decreases flow through smaller vessels and can cause tissue hypoxia.

Question 39

acute phase of burns (cont)

Answer 39

During Acute Phase anemia often develops as a result of hemodilution but usually is not severe enough to warrant a blood transfusion.
Abnormalities in coagulation may include decreased platelets ( thrombocytopenia) and prolonged clotting and prothrombin times.

Question 40

cardiac changes of burns

Answer 40

During Acute Phase anemia often develops as a result of hemodilution but usually is not severe enough to warrant a blood transfusion.
Abnormalities in coagulation may include decreased platelets ( thrombocytopenia) and prolonged clotting and prothrombin times.

Question 41

pulmonary changes with burns

Answer 41

Direct injury to the lungs from contact with flames rarely occurs. Problems are caused by inhalation of superheated air, steam, toxic fumes or smoke.
Direct Airway Injury:
a. Causes inflammatory reaction with edema
and airway obstruction. Possible at any
time during first 48 hours.
b. Patient becomes hoarse, has a brassy cough,
has difficulty swallowing and may have stridor
and wheezing.

Question 42

carbon monoxide poisoning with burns

Answer 42

a. One of leading causes of death associated
with fire.
b. Is rapidly transported across the alveolar
membrane & binds with HGB in place of
oxygen. Reduces oxygen delivery to tissues.
c. Vasodilating effect causes “cherry red “
color.
d. Effects: Headache, decreased cerebral
function, nausea, drowsiness, dysrhythmias, coma,
convulsions and possible death

Question 43

thermal heat injury

Answer 43

a. Usually limited to upper airway. Most
damage occurs above the true vocal cords.
b. Can produce airway obstruction anytime
during resuscitation. Need early intubation.
c. Inhaled steam can injure lower respiratory
tract since H2O holds heat better than dry
air.
d. Ulcerations, redness, & edema of the mouth
and epiglottis are first signs of upper airway
obstruction. Stridor, hoarseness, and shortness of breath
can also be seen.

Question 44

smoke poisoning

Answer 44

a. Caused by inhalation of toxic by-products
produced when plastics and home
furnishings are burned like hydrogen
cyanide.
b. Causes loss of ciliary action and severe
mucosal edema. Surfactant activity is
decreased causing atelectasis.
c. In a few hours, sloughing of the
tracheobronchial mucosa may occur and patient
expectorates mucopurulent material with carbon
particals.

Question 45

restrictive defects burns

Answer 45

. Full thickness burns encircling neck &
thorax may result in great edema that
can compress trachea and occlude airway.
b. Chest excursion may be greatly restricted
resulting in decreased tidal volume.
c. May be decreased lung compliance, non-
cardiogenic pulmonary edema, and ARDS
d. May need to do escharotomy or fasciotomy
to relieve the restriction.

Question 46

factors determining inhalation injury

Answer 46

Those injured in a confined space.
Those with extensive burns or burns to face.
Intra-oral charcoal, especially on teeth & gums.
Those unconscious at time of injury.
Those with singed hair, nasal hairs, eyelids & eyelashes.
Those coughing up carbonaceous ( sooty) sputum.
Changes in voice like hoarseness or brassy cough or stridor. Use of accessory muscles to breathe.
Poor oxygenation and ventilation. Wheezing, bronchospasm & labored respiration.
Edema, erythema & ulceration of airway mucosa.

Question 47

immunological effects of burns

Answer 47

Is a loss of skin integrity and there are abnormal inflammatory factors.
Altered levels of immunoglobulins and a reduction in lymphocytes.
Loss of skin surface also results in inability to regulate body temperature in early post burn. May manifest a low body temperature.
As hypermetabolism resets core temperature, burn patients may become hyperthermic for much of post burn period, even in absence of infection.

Question 48

metabolic effects of burns

Answer 48

Serious burns increase metabolic needs by 100%.
The patient’s oxygen and caloric needs are high. The increased production and loss of heat breaks down protein and fat (catabolism) so body uses glucose & calories causing a nitrogen loss.
Patient’s caloric needs double or triple normal caloric needs. Needs peak 4 to 12 days post burn and can remain elevated for months until all wounds are closed.

Question 49

gastrointestinal effects of burns

Answer 49

Decreased peristalsis & bowel sounds can result in paralytic ileus. Gastric distention & nausea may lead to vomiting unless gastric decompression is initiated.
Gastric bleeding may be seen in vomitus and in stools. Can develop stress ulcers. Need to be on proton inhibitor.

Question 50

renal effects of burns

Answer 50

Changes r/t decreased renal blood flow in emergent phase causes urine to be concentrated with a high specific gravity.
Other substances may be present in blood that flows through kidneys. Destroyed RBCs release HgB and potassium. When muscle damage occurs a large oxygen carrying protein called myoglobin is released from damaged muscle and circulates to kidneys.
Damaged cells release proteins that form uric acid. These large molecules may precipitate in kidney tubular system. May block blood & urine flow and may cause renal failure.
Burgandy colored urine may indicate deep muscle burns.

Question 51

survival predictions of burns

Answer 51

Best in children and young adults (5 to 40 yrs)
Burns of about 60% have 50% mortality
Burns more than 20% endanger life
Prognosis depends on depth & extent of burn and condition & age of patient.

Question 52

care of emergent phase of burns

Answer 52

Priorities:
First Aid
Prevention of shock
Prevention of respiratory distress
Wound assessment and initial care
Treatment of concomitant injuries

Question 53

emergency room care burns

Answer 53

Maintain airway, breathing and circulation. May need endotrach or trach to maintain airway. May need humidified oxygen. May need suctioning.
Determine fluid resuscitation. Needs central line.
Put in foley for hourly outputs.
Put in nasogastric tube for gastric decompression. Patient NPO
Manage pain with IV narcotics.
Assess circulation distal to circumferential burns.
Get height & weight. Give tetanus injection
Do initial wound assessment. Determine wound care.
If inhalation injury suspected may need emergency bronchoscopy
Needs to be in a Burn Center

Question 54

fluid resuscitation for a burn patient

Answer 54

Parkland (Baxter) formula:
4ml lactated ringers X kg body weight X % TBSA burned= total 24 hour fluid requirements. Give ½ of amount over first 8 hours and the rest of the amount over 16 hours.

Brooke (Modified) formula:
2ml lactated ringers X kg body weight X % TBSA burned = total fluid requirements. Give ½ amount of fluid over 8 hours and the rest over 16 hours.

Winski formula:
2ml lactated ringers X kg wgt X % TBSA burn with maintenance fluid

In addition to these fluids sometimes they need to give albumin and other IV fluids. Is a guideline.

Question 55

what makes a burn severe

Answer 55

if its of eyes, ears, face, hands, feet or perineum

Question 56

how to calculate fluids for burns

Answer 56

multiply weight (kg), by 4 ml, % of body burned. Then you divide that in 1/2. give 1/2 over first 8 hrs. give 2nd 1/2 over second 8 hrs.

Question 57

parameters for fluid of burns

Answer 57

alert and oriented 
30-50 ml an hour of output
below 100 bpm
systolic BP at least 100 and above
central venous 5-10 m of mercury
central wedge pressure 5-15 m of mercury

Question 58

what should you not have in a burn patients room

Answer 58

plants!! They carry pseudonomas.

Question 59

what kind of procedure is it when dealing with a burn patient

Answer 59

sterile technique. sterile gloves. sterile everything.

Question 60

burn care: intermediate/acute phase

Answer 60

Begins 48 to 72 hours after burn injury. Mobilization of fluid from interstitial space to intravascular space. Phase is concluded when burn area is completely covered by skin grafts or when wounds are healed. May take weeks to months.
There is continued attention directed toward assessment and maintenance of:
a. Cardiopulmonary function
b. Fluid and electrolyte balance
c. Gastrointestinal function
Burn wound care becomes another major focus of this stage. Goals are to:
a. Cleanse and debride area of necrotic tissue that could promote
bacterial growth.
b. Promote wound re-epithelialization and/or successful skin grafting.

Question 61

which phase does hypokalemia take place in burns

Answer 61

intermediate acute phase

Question 62

pathophysiology of acute phase of burns

Answer 62

Is state of diuresis with fluid shifting back to intravascular space. May see:
a. Hemodilution causing decreased Hematocrit. Blood cell concentration
is diluted as fluid enters vascular compartment. Also there is a loss
of RBCs destroyed at the burn site.
b. Increased urinary output because there is increased blood flow to the kidneys
which causes increased urine to form.
c. A sodium deficit continues because with diuresis sodium is lost with water and
the existing serum sodium is diluted by fluid coming into the vascular space.
d. May see a potassium deficit because potassium shifts back into the cells.
e. Metabolic acidosis can still be seen because the loss of sodium depletes
bicarbonate.

Question 63

which phase is more on wound care (burns)

Answer 63

acute phase

Question 64

burns cardiopulmonary effects

Answer 64

As capillaries regain their integrity, fluid moves from the interstitial space to the vascular compartment. Diuresis occurs. Happens 48 hours or more post burn..
If cardiac and renal functio0n are not adequate, fluid overload occurs with CHF.
Patient may need fluids titrated. Cardiotonic drugs and diuretics may be necessary. If blood transfusions are necessary to treat blood loss & anemia, the patient must be carefully monitored. May need Swan-Ganz cath to monitor for fluid overload.
Airway obstruction as a result of upper airway edema can take as long as 48 hours post burn to develop.

Question 65

neurological effects of burns

Answer 65

Patients can exhibit certain behaviors that aren’t totally understood.
May be very disoriented. May be withdrawn, combative. May hallucinate and have frequent nightmares. Delirium is more acute at night. Behaviors eventually disappear.
May be due to hypoxia, cerebral edema, sepsis, ICU psychosis and medications being given

Question 66

gastrointestinal effects of burns

Answer 66

Bowel sounds do return during this stage but the patient is still able to get a paralytic ileus.
May also have diarrhea from enteral feedings and antibiotics. May have constipation from opioids.
May also have Curling’s ulcer and need proton pump inhibitors.
Will have transient elevated glucose levels needing glucoscans and insulin coverage.

Question 67

musculoskeletal effects on burns

Answer 67

As burn begins to heal & scar tissue forms, the skin becomes less supple and pliant. ROJM may be limited and contractures can form.
Because of pain patient tends to be in a flexed position also leading to the formation of contractures.
Splinting, proper positioning, and ROJM can help to prevent contractures.

Question 68

risk for infection burns

Answer 68

Infection can be a major cause of death for patients who survive the first few days post burn. Begins at burn site but can be carried into the blood stream causing sepsis.
The most invasive wound infections are caused by pseudomonas, enterobacter, klebsiella, staph. aureus, candida and e. coli.
Cultures of the burn wound should be done on admission and then twice a week.
Symptoms of sepsis include hypo or hyperthermia, increased heart rate & respirations, decreased BP & decreased urinary output. May also have chills, malaise, and loss of appetite. WBCs usually 10,000 to 20,000 since patient is immunosuppressed.
If infection is suspected, need to get cultures wound, blood, urine, IV site, pharynx, and sputum

Question 69

symptoms to look for infection in burns

Answer 69

any of these factors could mean sepsis. 
slight temp, Hypo or hyperthermia 
pulse starts to elevate
respirations start to elevate
b/p decreases
urinary output starts to decrease

Question 70

nutritional needs for burns

Answer 70

A total assessment of nutritional needs is crucial to decrease catabolic states.
The nurse and nutritionist collaborate to evaluate the patient’s energy needs.
Enteral feedings may be needed to reverse negative nitrogen balance and to offset the hypermetabolism. Enteral feedings are contraindicated in with Curling’s ulcers, pancreatitis, and septic ileus. May need parenteral nutrition.
As the patient begins to tolerate po feedings the enteral feedings can be titrated off.
The patient will need high protein, vitamins A, C, E and a multivitamin with minerals such as zinc and iron to promote healing and hemoglobin formation.
Encourage family to bring in favorite foods. Calorie counts & weekly weights.
Offer burn frappes and snacks between meals. Avoid activities around meal time.

Question 71

skin debrediment burns

Answer 71

Need to remove necrotic tissue because it retards healing and prolongs inflammmation. Is the process of removing dead tissue from the wound.
Types of Debridement:
a. Natural debridement allows dead tissue to spontaneously separate
from wound.
b. Mechanical debridement uses a surgical scissors & forceps to
separate and remove eschar. Done to the point of pain & bleeding.
c. Enzymatic debridement uses an agent topically to dissolve and
remove necrotic tissue.
d. Surgical debridement excises the wound sequentially to the level
of the fascia. Since this sacrifices viable fat & lymphatic tissue,
it’s use is reserved for patients with extensive or full-thickness burns

Question 72

skin grafting burns

Answer 72

Priority areas are face, hands, feet, and areas involving joints. Permits earlier functional ability and reduces development of contractures.
When burns are extensive on the chest and abdomen, grafting may be done to reduce extent of burn surface.
Should have bacterial count of fewer than 100,000/gram of tissue to optimize graft take. A pre-op culture to r/o streptococcus is mandatory because the enzymes of this bacteria can dissolve the graft.
Types of Grafts:
a. Autograft is the patient’s own skin. Taken from donor sites. Can also
grown via culture if larger pieces are needed.
b. Homograft or Allograft is human skin harvested from cadavers.
Rejected in 14 to 21 days.
c. Heterograft or Xenograft is skin from an animal like a pig. Only temporary.
Rejects early and more of a risk for infection.
d. Synthetic materials like Biobrane

Question 73

complications of burns

Answer 73

Scars more likely if burn is below the level of the dermis. Wound is in a dynamic state for 1 to 2 years post burn. If appropriate measures are employed scar tissue will lose its redness and will soften. Jobs elastic garments help.
Keloids are large heaped up masses of scar tissue that may extend beyond the wound surface. Seen more in dark pigmented persons.
Failure to heal r/t inadequate nutrition. A serum albumin level below 2gm/dl is frequently a factor.
Contractures because the burn wound will shorten and the flexor muscles are stronger, Splints, traction, purposeful movement and positioning in functional alignment help to prevent these.
Morphine, MS contin, dilaudid, fentanyl and methadone may be used for analgesia. NSAIDS and neurontin may also be used

May use ativan and versed to decrease anxiety and give short acting amnesia

Question 74

wound care burns

Answer 74

Need daily observation, assessment, cleansing, debridement and dressing application.
May have to perform non-surgical debridement, dressing changes, topical antibiotic treatment, graft care and donor site care twice a day.
May use hydrotherapy like a showering cart to cleanse wounds.
During wound care pain management is needed. Narcotics, distraction, guided imagery and relaxation techniques can be used.
Allow the patient to participate if possible to lower the patient’s anxiety.
Multiple layers of gauze may be applied over topical agents on the wound depending on the depth of the injury, amount of drainage expected, area injured, and patient’s mobility. May be held in place by roller gauze or netting fabrics.

Question 75

nursing assessment burns

Answer 75

Vital signs, peripheral pulses, weights, pain level burn wound.
Cardiopulmonary assessment
Neurological , gastrointestinal assessment
Laboratory findings

Question 76

nursing interventions burns

Answer 76

Prevent cardiopulmonary complications and infection
Maintain skin integrity
Manage pain
Maintain nutrition
Emotional support/help with body image
Prevent hazards of immobility
Patient teaching

Question 77

topical wound agents for burns

Answer 77

BACITRACIN
Antimicrobial agent. Used for partial thickness burns. Is painless and
easy to apply. Wound should be cleansed thoroughly
between dressings. Reapplication 2 to 4 times a day.
GENTAMYCIN 0.1%
Broad spectrum antibiotic for partial thickness burns. Is painless and
easy to apply. Reapplication 3 to 4 times a day.
XEROFORM (COVIDIEN)
Petrolatum based fine mesh gauze impregnated with 3% bismuth
tribromophenate. Mild antimicrobial abilities. Provides
a protective barrier dressing that allows for epithelial tissue
development. Does not manage high volumes of exudate.
Apply to clean wound. Dressing becomes rigid as it dries onto wound.

Question 78

topical wound agents burns

Answer 78

SILVER-SULFADIAZINE (SILVADENE)
Broad spectrum cream against gram negative & gram positive bacteria
and Candida organisms. Used for deep partial and full
thickness burns. Penetrates eschar to inhibit bacterial
growth at dermis-eschar interface. Inhibits epithelial tissue
development. May cause skin rash and transient decrease
WBCs for 24 to 48 hours after application. Contraindicated
for sulfa allergies. Change dressing every 12 to 24 hours.
Apply ¾ inch layer directly to wound or impregnated gauze.
Is painless and somewhat soothing. May cause slimy, grayish
appearance. Discontinue when eschar is gone.

Question 79

topical wound agents burns

Answer 79

AQUACEL AG
Composed of 1.2 % ionic silver. Creates a gel that absorbs wound
drainage. Used for partial thickness and full thickness
burns. May be covered by another dressing. Trim edges as it
lifts. May leave yellow film-do not remove completely. Apply
new dressings to cleansed wound. Can stay on up to 14 to 21
days. Has antimicrobial properties. Dressing becomes rigid
when it dries out, decreasing range of motion. May cause
pain as dressing dries out. May cause pain as dressing
dries out.

Question 80

topical wound agents burns

Answer 80

MAFENIDE ACETATE (SULFAMYLON)
Used for deep partial and full thickness burns especially ear burns.
Effective against broad range of micro-organisms including
pseudomonas and clostridium. Available as a water soluble
cream or 5% topical solution. Penetrates thick eschar and
cartilage. Inhibits epithelial tissue development. Plan for
pain management on application. Apply cream in ¼ inch layer
directly to wound or impregnate into gauze dressing BID orTID.
Monitor for metabolic acidosis (inhibits carbronic anhydrase
activity). Monitor for allergic rash. Use with caution in renal
patients. Cleanse and debride burn areas before reapplying.
Discontinue when eschar gone.

Question 81

topical wound agents burns

Answer 81

HYDROCOLLOIDS
Contains gelatin, pectin, carboxy-methylcellulose together with polymers
and adhesive. Used for small partial or full thickness burns.
Absorbs exudate, forms viscous gel and is impermeable to
bacteria. Reduces pain. Change dressing q 3-5 days. Helps
with autolytic debridement. Good for minimal to moderate
drainage. May macerate skin if drainage exceeds dressing’s
ability to absorb it. Example: Duoderm

Question 82

topical wound agents burns

Answer 82

BIOBRANE
Is a biosynthetic dressing made of silicone film bonded to a nylon
membrane with collagen. Acts as a temporary dermal
substitute for partial thickness and donor sites. Pores in
membrane allow for dissipation of exudates. Closes wound
and stays on until wound is healed. Reduces pain. Needs
to be applied within 24-36 hours. No antimicrobial action.

Question 83

dermal replacements / synthetic substitutes

Answer 83

INTEGRA (ARTIFICIAL SKIN)
Two layer man-made membrane used to replace dermis. Is covered
with an autograft forming a functional dermis and epidermis.
ALLODERM
Man-made collagen matrix used to provide a dermal layer. Is covered
with an autograft.

Question 84

rehabilition phase burns

Answer 84

Begins when patient’s burn wounds have healed and the patient is able to resume a level of self care activity.
The goals are to assist the patient to resume a functional role in society & to accomplish functional and cosmetic reconstructive surgery.
Still may have some electrolyte problems like:
a. Calcium Deficit
b. Potassium Deficit
c. Negative nitrogen balance

Question 85

pathology changes and manifestations of burns

Answer 85

Burn wounds heal by either primary intention or by grafting, New skin appears flat and pink. In 4-6 weeks area becomes raised and hyperemic. If ROJM is not done, new tissue will shorten causing contractures.
Mature healing takes 6 months to 2 years when suppleness returns and pink or red color has faded to a slightly lighter hue than unburned tissue.
Takes longer for heavily pigmented skin to regain it’s color because many of the melanocytes are destroyed. Often skin never regains the original color.
Scarring has two parts: discoloration and contour. Discoloration will fade with time but scar tissue tends to develop an altered contour. It no longer is flat but becomes elevated and enlarged above the original burn area.
Pressure can help keep the scar flat. Gentle pressure can be maintained
with Job’s custom fitted garments. These are worn up to 23
hours for as long as 12 to 18 months post burn. Are removed
only for a short time for bathing.

Question 86

pathology changes and manifestations of burns

Answer 86

Patient frequently experiences itching when healing is occurring. “Corrective Concepts” a water-based moisturizer and benadryl can help decrease the itching. Old epithelium is replaced by new cells so flaking happens.
Newly formed skin is extremely sensitive to trauma. Blisters and skin tears are likely to develop from slight pressure or friction. Skin is hypersensitive to cold, heat, and touch. Grafted areas are more likely to be hyposensitive until nerve regeneration occurs.
Healed burn areas must be protected from direct sunlight for 6 to 9 months to prevent hyperpigmentation and sunburn injury.

Question 87

collaborative care burns

Answer 87

Both patient and family are encouraged to actively participate in care. The patient may go home with small unhealed wounds so education and hands-0n instruction for dressing changes and wound care are needed.
Emollient water-based creams should be applied to skin that penetrate the dermis to keep the skin supple and to decrease itching.
Continued Physical and Occupational Therapy is needed. Constant encouragement and reassurance is needed to maintain a patient’s morale, especially when the patient realizes recovery can be slow and rehabilitation will need to be the major focus for the next 6 to 12 months.
There is a tremendous psychological impact on the patient so we need to be sensitive and attuned to the patient’s emotions and concerns. Patients need to be encouraged to discuss their fears regarding loss of their lives as they knew it, loss of function (temporary or permanent ), deformity & disfigurement, retun to home-life & work, and financial burdens.

Question 88

collaborative care burns cont.

Answer 88

Need to address spiritual & cultural needs. Early on bring family up to speed about situation, hospital chaplains, and community help groups.
A person’s self-esteem is usually adversely affected by burns. Patient may have an overwhelming fear of the loss of a relationship. Encourage appropriate independence, and eventual return to pre-burn levels of activity. Interactions with burn survivors may bring comfort and help to restore self-esteem.
Counseling services should be made available after the patient returns home.
Patients need reassurance that their feelings during this time of readjustment are normal and that frustration is to be expected.
Stress from the burn injury can sometimes precipitate a psychiatric/psychological crisis. Experience may be beyond the patient’s ability to cope. Short term counseling is helpful.

Question 89

Common emotional responses of burn patients

Answer 89

FEAR: Will I die? What will happen next? Will I be disfigured? Will my family and friends still love me?
ANXIETY: I feel out of control. What’s happening to me? When will it end?
ANGER: Why did it happen to me? Those nurses enjoy hurting me.
GUILT: If only I’d been more careful. I’m being punished because of something I did.
DEPRESSION: It’s no use going on. I don’t care what happens to me. I wish people would leave me alone.

Question 90

rehab phase burns

Answer 90

try to get them to return to society
do cosmetic surgery here
new skin looks flat and pink, if you don't do something it raises and do hyperemic
need to do ROM to prevent contractions
takes 6 months to 2 years to heal
pink or red color fades
make sure to use Jobes (compression)
if your heavily pigmented it takes longer for color to return

can still be anemic in this phase
need nutritional stuff, vitamins, still have electrolyte problems
still need to have blood work done
itching is the worst as they are healing
need to prevent scratching

Question 91

what to know for test

Answer 91

different phases of burns
fluid shifts
how to calculate fluid for burns
know the dressings for burns
alignment and functional position is very important to prevent contractors
appreciate the emotional toll it takes
what we are monitoring for in burns
know full thickness meds
know parkinson’s and dopamine
know parkinson’s stages
know to keep patient functional as long as possible with parkinson’s
tremors, rigidity, akinesea, posture,
monitor orthostatic hypotension parkinson’s
sinimet with parkinson’s (major drug)
some parkinson’s drugs sometimes peter out, need a drug holiday.
know MS and immune modulator drugs
know how immune modulator drugs are given and who has to learn to do it
what might you get when starting immune drugs (flu like symptoms)
immune drugs cause blood disgratiors and liver issues
no side effects of revib, copazone (MS)
most important about MG (give drugs on time,) drugs can kick it off. take this into account. plasmaphoresis before surgery
know difference between MG crisis and colinergic crisis
whens the best time to get calories into MG (morning)
rest before you feed them (MG)
what should you focus on with LG disease (communication before they lose it, advanced directives)
LG can have a heredity factor (children should be tested)
Huntinton’s you need to test its inherited
CVA’s know difference between right and left stroke
different conditions of CVA’s (whats aphasia, ataxia….)
know about care for CVA’s
know broca’s and weirnekies
know ICP
seizures (generalized vs. partials)
crucial to document everything you see with a seizure. very detailed length, aura, what was jerking, how long did postdictal phase last
airway and safety with a seizure
very important for them to stay on meds (seizures)
ativan is drug of choice for seizures
gingaval hyperplasia with dilantin
brain tumors - positioning with incisions and approach for after surgery (flat, log rolled, semi fowlers?)
how to assess spinal cord injury,
know difference between different kinds of spinal injuries
has to be moved in alignment,
certain care has to be given depending on place of injury
know spinal shock
know differences in hematomas with head injuries, what do we do across the board, concussions, contusions, lacerations.
CT with any head injury.