burns Flashcards
burns patho
increased capillary permeability causes plasma to seep out into the tissue (fluid leaks out of the vessels)
worry about shock within the first 24 hours
pulse increases r/t FVD
CO decreases r/t less volume to pump out
urine output decreases r/t kidneys not being perfused
epinephrine secreted and vasoconstrict to shunt blood to vital organs
ADH and aldosterone secreted to increase blood volume (ADH retains H2O, aldosterone retains Na and H2O)
classification of burns
extent
depth
burn location
risk factors
extent
rule of 9s head and neck 9 trunk front 18 back 18 genital 1 arm 9 (each) leg 18 (each)
depth
partial: 1st and 2nd degree
full: 3rd and 4th degree
burn location
face, neck, or chest: breathing issues
hands, feet, joints, or eyes: everyday issues
risk factors
heart, lung, or kidney disease
pre-existing diabetes or peripheral vascular disease (dont heal well)
young and old (thin skin and less subQ fat so burn can go deeper and cause more complications)
BSA is less in young `
treatment for burns
stop burning process (wrap in blanket, cool water no more than 10 minutes, remove jewelry, remove non-adherent clothing and cover the burns)
focus on airway
may intubate prophetically
inhalation injury
client is hypoxic
treat with 100% O2
hydrogen cyanide
treat with 100% O2
antidote at hospital
if they are in a closed space: at risk for more complications
indicators of inhalation injury
singed nose hair singed facial hair soot on face coughing up secretions with dark specks difficulty swallowing wheezing blisteres on oral mucosa hoarseness substernal/intercostal retractions and stridor = BAD
fluid replacement for burns
2 large bore IVs
crystalloids (LR) and colloids (albumin)
*** note time of burn r/t fluid replacement in first 24 hours depends on the time the injury occurred
fluid replacement calculation
1st 8 hours: 1/2 of total volume
2nd 8 horus: 1/4 of total volume
3rd 8 hours: 1//4 of total volume
(2-4mL of LR) x (body weight in kg) x (%of TBSA burned) = fluid required in first 24 hours
nursing priority with burns
hypoxia
how can you tell if fluid replacement is working for those with bursn
urine output
minimum of 0.5 to 1ml/kg/hr (30-50ml/hr for adults)
electrical injuries: 75-100ml/hr
1ml/kg/hr for children
meds for burn pts
albumin (colloid)
within the first 24 hours holds fluid in vascular space vascular volume increased kidney perfusion increased blood pressure increased cardiac output increased **** putting more fluid in vascular space workload of heart will increase *** vascular volume will increase when giving albumin
albumin alert
stress the heart too much can go into FVE
cardiac output will decrease
crackles
to ensure that an infusion is not overloading the client take the CVP hourly
pain management for burn pts
assess respirations when giving narcotics
IV meds
drug of choice: opioids
immunizations for burns
tetanus (active immunity) takes 2-4 weeks to develop their own immunity
immune globulin (passive immunity) provides immediate protection
systemic antibiotic therapy
broad spectrum are avoided but will only be used until cultures have returned
collect cultures before starting antibiotics
*****when giving mycin drugs WORRY when the clients BUN or Cr increase or if they report hearing loss. mycin drugs can lead to ototoxicity (irreversible hearing loss) or nephrotoxicity
topical medications for burns
silver impregnanted dressings provide broad antimicrobial effects
can be left in place for 3-14 days
mafenide acetate: can cause acid base issues and stings
silver nitrate: keep wet, electrolyte issues
antimicrobial ointments
need to be alternated r/t drug tolerance
apply a thin layer using sterile gloves
asepsis is critical
can use light gauze to cover
debridement
used to remove necrotic dead tissue
Sutilains or Collagenase (enzymatic drugs that eat dead tissues)
dont use on face
dont use if pregnant
dont use over large nerves
dont use if area is opened to a body cavity
hydrotherapy: need to monitor pain management
grafting
autograft: own skin (dressing until bleeding stops and then left open to room air)
can reharvest from the same donor every 12-14 days if healthy
poor circulation if blue or cool
tuberculin syringe and aspirate blood or exudate from under the graft or roll qtips over the graft if air, blood, or exudate is accumulating under the graft
nutrition for those with burns
more cals
protein and vitamin C are needed to promote healing
check pre-albumin to ensure proper nutrition and positive nitrogen balance
circulation complications
check circulation if circumferential burns
elevate extremity
decreased vascular check–> escharotomy and fasciotomy to relieve pressure and restore circulation
**the fasciotomy cut is much deeper into the tissue and through the fascia of the muscle
circulatory check
pulse
skin color
skin temp
CRT
renal system for burn pt
monitor catheter hourly
kidneys retain H2O so may not have urine when inserted right away
Mannitol is used to flush kidneys
can see brown or red urine
kidney failure if output is less than 30ml/hr
diurese after 48 hours r/t fluid going into vascular space so worry about FVE
electrolyte imbalance for burn pt
most of K is inside the cell
cells rupture (lysis) during burns
serum K increases (vascular space)
hyperkalemia
GI system r/t burns
magnesium carbonate, pantoprazole, and famotidine to prevent stress ulcer (Curling’s ulcer)
*** watch for occult blood in stool and coffee ground emesis
NPO and hooked up to NG suction to prevent paralytic ileus
remove NG tube when you hear bowel sounds
integumentary system r/t burns
contractures: wrap each finger separately and use splints to prevent, hyper-extend the neck (head is back), no pillows
infection: perineal=infection, eschar (dead tissue) needs to be removed and if not then it cannot regenerate, bacteria likes to grow in eschar tissue
chemical burns
remove and begin flushing the skin/surface
flush with water 15-30min (cool or sterile saline)
brush powder chemicals first and then flush
electrical burns
entrance and exit (internal damage)
continuous heart monitoring for 24 hours
at risk for vfib
myoglobin and hemoglobin can build up and cause kidney damage
placed on C-collar and spine board
amputations common (circulation is destroyed)
Complications: cataracts, gait issues, neurological deficit
