Burns Flashcards
Major burns
25 percent or more of TBSA/adult
10 percent or more of TBSA/children
Response of the body
Systemic
Burn affects
All systems of the body
FIRST STEP
airway patency
SECOND STEP
oxygen
THIRD STEP
vitals
FOURTH STEP
IV line and fluid replacement
FIFTH STEP
elevate extremities
SIXTH STEP
keep warm and put on NPO
Superficial-thickness burn (first degree) 6
- only epidermis
- dry/pink to red
- no blistering
- blanching is present
- pain eased by cooling
- healing in 3-6 days
Superficial partial-thickness burns (second degree) 4
- into dermis
- moist red blanching blistering edematous
- sensitive to cold air
- 10-21 days
Deep partial-thickness burns (second degree)
- deeper into dermis
- No blistering
- Red and dry with moderate edema
- May need grafting
- Scar formation and perhaps contractures
- soft and dry eschar
- 3 to 6 weeks
Full thickness (third-degree)
- into the fatty layer of the skin
- dry hard leathery eschar
- severe edema
- reduced or absent sensation
- removal of eschar and grafting is necessary
- weeks to months
deep-full thickness burns
- muscle tendon and bone are damaged
- black and no sensation whatsoever
- severe edema
- grafts are required
Major priorities
prevention of infection and wound closure
Thinner skin, sensory impairment, decreased mobility
increased depth of injury, and increased risk of burn injury
slower healing time
greater infection and loss of function risk
reduced inflammatory and immune responses
increased risk for infection/sepsis, no fever
pre-existing conditions
can interfere with wound healing
circumferential burns of extremities
compartment syndrome
circumferential thorax burns
inadequate chest wall expansion and pulmonary insufficiency
Mortality rate
higher younger than four and birth to one, older than 65 years
Assessment findings in inhalation injury
- facial burns
- singed hair, eyebrows, and eyelashes
- black carbon particles in the nose, mouth, and sputum
- edema of the nasal septum
- drooling
- difficulty swallowing
- tachy
- agitation and anxiety
- wheezing, dyspnea
- edema in the oropharynx and nasopharynx
For inhalation injuries
IMMEDIATELY PLACE UPRIGHT
Vasoactive substances
cause an increase in capillary permeability
Extensive burns
generalized body edema, decrease in circulating blood volume
Fluid losses result in…
a decrease in organ perfusion
Heart rate, blood pressure, and cardiac output…
increases, decreases, and decreases.
Hyponatremia and hyperkalemia…
occur.
Hematocrit levels…
increase.
The kidneys start with…
oliguria
Gastrointestinal tract…
intestinal ileus and gastrointestinal dysfunction
Pulmonary hypertension
decrease in lung compliance and oxygen
Primary goals in resuscitation/emergent phase
maintain airway, administer IV fluids, preserve organs
Conserve body heat and get an IV going.
Major burns
Administer 100 percent oxygen with a nonrebreather mask until the carboxyhemoglobin level is below 15%.
Maintain urine output.
NPO status (until bowel sounds are heard)
NG tube
Administer tetanus.
Minor burns
Active range of motion exercises and wound care treatments
Resuscitative Phase
Begins with fluid initiation.
Ends with capillary integrity mainly intact and large fluid shifts decreasing.
Prevent shock!!
Fluids are calculated from time of injury.
Elevate head of bed to 30 degrees.
Initiate ECG monitoring.
Monitor daily weights (expect a weight gain of 15 to 20 pounds in the first 72 hours).
Prevent stress ulcers.
Watch for occult blood.
Urine output needs to be between 30 to 50.
Elevate burns of the extremites above the heart.
No diuretics.
Keep room warm.
Keep sterile sheets off of client’s skin
Watch myoglobin and hemoglobin levels.
No pain meds via oral route.
Don’t do subq or IM injections.
Diet high in protein, carbs, fats, vitamins (more than 5000 calories).
Daily weights.
Acute phase
Restorative therapy until wound closure.
The client is stable, capillary permeability is restored, diuresis.
48-72 hours.
Infection control, pain management, physical therapy, nutritional support.
Escharotomy
no anesthesia
pack it with fine mesh guaze
Fasciotomy
general anesthesia
Hydrotherapy
30 minutes or less
Premedicate!!
Not used for unstable clients or those with new skin grafts.
Maintain body temp!!
Autografting
Immobilization of graft site and elevation
Monitor for infection suspicions.
Protect from sunlight.
Donor site needs to be kept clean, dry, and free from infection.
Apply lotions.
Rehabilitative phase
Increase strength and function…provide emotional support…minimize deformities…promote wound healing.
Fentanyl
can prevent oversedation
Longer procedures
use morphine
