Burns Flashcards
Why does plasma seep out into the tissue
Increased capillary permeability
When does capillary permeability happen
first 24 hours
capillary permeability leads to
fluid volume deficit, shock, increased heart rate
why does cardiac output decrease in burns
less volume in vascular space
why does urine output decrease
kidneys holding on to fluid OR inadequate renal perfusion (only takes 20 minutes for acute tubular necrosis)
why is Epinephrine secreted
vasoconstriction to increase BP and shunt blood to vital organs
what other hormones are secreted
ADH (retain water) & Aldosterone (retain sodium and water)
what is the most common airway injury
Carbon monoxide
what are the S/S & Tx of carbon monoxide poisoning
S/S: cherry red color
Tx: 100% oxygen
burns that occur in close space increase the amount of CO that was inhaled
when you see a client with burns to face, chest, neck, facial hair, think what first
prophylactically intubation
Rule of 9s
burned area: head/neck -9% arm (each) -9% leg (each) -18% trunk (back) -18% trunk (front) -18% genital -9%
clients with burns over 20/30% of body
fluid replacement is the most important aspect of treatment.
when should fluid replacement therapy occur
first 24 hours after the time of injury
what is the parkland formula
(4ml of LR) X (body weight in kg) X (% of TBSA burned) = total fluid requirement for first 24 hours after burn
hrs 1-8: 1/2 the total volume
hrs 8-16: 1/4 the total volume
hrs 16-24: 1/4 the total volume
restlessness could indicate what
pain, hypoxia, inadequate fluid replacement
hypoxia takes prescience
in priority Qs refer to Maslow’s hierarchy
how do you determine client’s fluid volume is adequate
in Burns use Urine Output to determine fluid volume. In first 24 hours we are loading them with fluids because their vesicles are leaking (due to shock), so weight is not accurate.
what is normal urine output
0.5 ml/kg/hr -adults
1 ml/kg/hr -children
for adults minimum is 30-50 ml/hr
Emergency Management of burns
treat burn site with cool (not cold) water to stop burning process that still may be occurring.
wrap client in blanket to prevent heat loss and protect against germs
remove jewelry due to swelling of skin after burn and possibility that jewelry is still hot after burn
remove non-adhearent clothing to prevent swelling and cover burn site with clean dry cloth
signs of airway injury
singed facial hair, burnt hair, burnt nasal hair soot on face, coughing up black soot and sputum, blisters on lips/tongue/gums/oral pharyngeal mucosa
respiratory acidosis is possible due to shallow respirations
upper body burn is more dangerous due to airway restriction
medication management
Albumin increases vascular volume (Na & H2O)
hold fluid in vascular space, increase vascular volume, increase kidney perfusion, increase BP, increase cardiac output, corrects fluid volume deficit.
watch out for putting increased work load on heart and possibility of fluid volume excess
if fluid volume excess occurs, then CO will drop, lung sounds will be wet. Must take CVP measurements every hour to ensure client is not going into overload
Pain management
IV because it is fast acting and IMs won’t work due to poor muscle perfusion.
Immunizations
Booster shot (toxoid) is ACTIVE IMMUNITY -body must take ACTIVE role in making anti-bioties to agonist. Takes 2-4 weeks
IMMUNE GLOBULIN is IMMEDIATE protection, because the anti-bodies are supplied immediately to body in Immune Globulin. Lasts 3 Mo
circumferential burn
burn is all the way around (arm, leg)
NURSING PRIORITY: check pulses
Circulatory Check:
Pulse
Skin Color
Temperature
Capillary Refill
Escharotomy
circulation is restored & pressure is relieved by cutting through eschar (dead tissue)
Fasciotomy
relieves pressure & restores circulation by cutting deeper into tissue, through eschar and fascia
if you insert a foley and no urine is produced what is the cause?
Kidneys are either preserving the fluid they have left OR they aren’t being perfused adequately.
output should be checked every hour
what do you do if Urine is red or brown?
Call doctor. This is likely to happen, however it is still a concern.
Red -hemoglobin from RBC destruction
Brown -myoglbin from muscle tissue destruction
could clog kidneys and lead to renal failure
Manitol (osmotic diuretic) might be ordered to flush out kidneys.
one time EXCEPTION TO RULE: normally wont want to decrease the CO of a burn client, but to save kidney fxn diuretic is used
Manitol crystalized in solution if cold. Before administration observe for clarity, do not refrigerate, and use inline filter.
if Urine Output is less than 30 ml/hr what do we worry about?
Kidney Failure
Why will client begin to diurese after 48 hours
fluid is returning to vascular space. Now we worry about fluid volume excess.
UO should increase (depending on kidney fxn)
burn clients are at risk for what electrolyte imbalance
hyperkalemia. Most of our potassium is found inside the cell, with a burn the cells lyse and K+ ions are in the vascular space.
are antacids ordered for burn clients
to prevent curlings ulcer (stress ulcer in stomach with burn client).
Mylanta, Protonix, or Pepcid are ordered.
Antacids:
Amphogel, milk of magnesium
H2 Antagonist:
Zantac, Pepcid, Axid
Proton Pump Inhibitor:
Protonix, Nexium
why is client NPO and on NG tube suction?
likelihood of developing a paralytic illius, blood is shunted to vital organs away from intestines.
abdominal girth will increase
paralytic illus is caused by 1) low vascular volume (blood shunting) 2) normal stress response 3) Hyperkalemia (muscle weakness of intestines prevents movement -not as common)
nutrition
hypermetabolic state requires more calories, PROTEIN & VITAMIN C
NG tube feedings must pull back for a residual volume, hold feedings if over 50 ml & give residual back to patient (if you don’t, if could mean fluid, lyte, acid/base imbalance).
NG tube is removed after osculating bowel sounds
labs to ensure proper nutrition and positive nitrogen balance
PRE-ALBUMIN (quicker & more sensitive), total protein, & albumin.
contractures
skin is being pulled and off sets muscle development
if client has partial and full-thickness burns (especially 3rd degree).
classification of burns:
superficial thickness: formally called first degree burn; damage only to epidermis
partial thickness: formally called second degree burn; damage to entire epidermis and varying depths of the dermis
full-thickness: formally called third degree; damage to entire dermis, and sometimes fat.
special measures
separately wrap each finger
use hand/finger splint to prevent contractures
hyper extend neck as it’s healing to prevent contractures, don’t use pillow, promote chin to chest
perineal burn #1 complication
infection
eschar
dead tissue. It must be removed to promote new tissue growth and prevent bacterial growth
type of isolation
protective (reverse) isolation, protect them from us
travase or collagenase
enzymatic drugs to eat dead tissue
1) dont use on face (scarring)
2) dont use if pregnant
3) dont use over large nerve
4) dont use if area is opened to a body cavity
Hydrotherapy
used to debriefed. watch for cross contamination. medicate prior to Tx
Common drug used with burns
Silvadene - soothing, apply directly, if rubs off apply more, can lower the WBC, can cause rash
Sulfamylon -can cause acid base problems, stings, if it rubs off apply more
Silver nitrate -keep these dressings wet; can cause electrolytes problems
Betadine -stings, stains, allergies, acid-base problems
drugs should be alternated to prevent bacterial resistance or tolerance
why do we avoid broad spectrum antibiotics
to prevent super or secondary infections
broad spectrum may be used until the wound cultures come back
collect cultures BEFORE starting antibiotics
Mycin drugs
worry when BUN or creatinine increases or andy change is hearing
can cause OTOTOXICITY & NEPHROTOXICITY
stop if any hearing changes occur. If BUN or creatinine increase, assume it is nephrotoxic
grafts
site can be harvested every 13 to 14 days if well nourished
graft site is open wound, so cover until bleeding stops
if new skin graft is blue or cool then there is poor circulation
might need to use Q tip and do a spiral pattern to remove air & fluid under graft or else it will not adhere
chemical burn
flush with water for 15 to 20 minutes (if chemical is powder then brush powder off first).
electrical burn
there are 2 wounds; entrance and exit (exit will be much bigger)
electrical injury precaution
heart monitor for 24 hours
watch for V fib
watch Kidney Damage with myoglobin & hemoglobin buildup in rentals
place client in C collar because they may have fallen or contracted their muscles forcefully
why do amputations happen with electrical burns
electricity kills vascularity
cataracts, gait problems, and any neurological deficit (vessels and nerves get messed up)
