Burns part 2 Flashcards
Management of Airways (EP)
-early endotrachial intubation
-escharotomies of chest
-fiberoptic bronchoscopy
-humidified air and 100% O2
-High fowler’s position
-suctioning, chest PT
-bronchodilators
Nursing management of fluid (EP)
-2 large-bore IV lines for greater than 15% TBSA
-Central line might be needed for over 20 (book says 30)% TBSA
-Areterial line if frequent ABGs or invasive BP monitoring needed
-Use Parkland (Baxter) formula for fluid replacement (4 mL X weight (kg) X TBSA)
Nursing management of wound care - cleansing/debridement (EP)
Cleanse and gently debridement (remove dead tissue)
-can do on shower cart, in shower, or on a bed/stretcher
Surgical debridement
-in OR
-necrotic skin removed
-releasing escharotomies and fasciotomies might happen
(fasciotomies relieve swelling)
Nurse management- wound care: showers and dressings(EP)
Once-daily showers
-dressing changes in morning and evening –> antimicrobial dressings can stay for 3-14 days
nurse management: wound infection facts (EP)
infection can cause further tissue injury and possible sepsis
-source of infection is patient’s own flora from skin, respiratory, and GI
nurse management: wound care - open method (EP)
Burn is covered with topical antimicrobial
-no dressing over wound
-usually limited to care of facial burns
nurse management: wound care - multiple dressing changes/closed method (EP)
how often to change dressings?
sterile gauze dressings laid over topical antimicrobial
Dressings changed anywhere bt every 12 hrs to every 14 days
nurse management: wound care - staff percautions around open wounds
PPE
-disposable hats
-masks
-gowns
-gloves
use sterile gloves to apply ointment and sterile dressing
nurse management: wound care- grafts (EP)
used for what% TBSA?
allograft/homograft skin (for over 50% TBSAs)
-from skin donor cadavers
-used with newer biosynthetic options
nurse management: wound care - face and eyes
Face
- cover with ointment and gauze
- don’t wrap –> too much pressure
Eye care for corneal burns
-antibiotic ointment
-artificial tears for moisture and comfort
-periorbital edema might scare patient
nurse management: wound care - ears and hands/arms (EP)
Ears
-no pressure!
-no pillows!
-raise head with rolled towel
Hands and arms
-extended and elevated on pillows or foam wedges
-splints can be used on hands and feet
-wraps can reduce edema
nurse management: wound care - perineum (EP)
keep clean and dry
assess for indwelling catheter need –> if swollen internally
perineal care
fecal diversion device if loose stool
nurse management: wound care- lab tests and PT (EP)
lab tests to monitor fluids and electrolytes
ABGs to assess oxygenation
PT for ROM exercises
Nurse Management: wound care - drug therapy (EP)
Analgesics and sedatives
-morphine, Dilaudid, Haldol, Ativan, Midazolam
Tetanus immunization - routine for burns
Antimicrobial agents
-Topical = silver sulfadiazine and mafenide acetate
-systemic are uncommon, but are used if sepsis
VTE prophylaxis
-low weight heparin or low dose unfractioned heparin
-pneumatic compression devices or graduated compression stockings if high bleeding risk
IV pain med for fast action
Nurse management: wound care - nutritional therapy (EP)
-only important after fluid replacement happens
early and aggressive nutrition support within hours of injury
-lessens complications/mortality
-optimizes healing
-minimizes effects of hypermetabolism and catabolism
Hypermetabolic state in burn healing
-how to deal with it
BMR increases by 50-100%
core temp is raised
catecholamines increase, stimulating catabolism
Early, continuous enteral feeding promotes optimal healing
adequate calories and protein - careful bc of renal isues
supplemental vits and iron
Acute phase beginning and end
Starts with mobilization of extracellular fluid and subsequent diuresis
Ends when
-partial thickness wounds are healed OR
-full thickness burns are covered with grafts
What happens during acute phase?
diuresis –> less edematous
Bowel sounds return
-healing starts as WBCs surround burn wound
-necrotic tissue sloughs off
-granulation tissue forms
-partial thickness burns heal from edges and dermal bed
-full thickness burns have eschar removed and skin grafts applied
Clinical manifestation (AP)
-what happens with partial and full thickness wounds?
partial: eschar is removed and re-epithelialization begins
full: surgical debridement and skin grafting
Lab values: sodium (AP)
Hyponatremia can happen bc GI suction and diarrhea
-also water intoxication from excess intake –> offer liquids other than water
Hypernatremia could happen after fluid resuscitation
-also improper tube feedings or inappropriate fluid administration –> limit Na
Lab values: potassium (AP)
Hyperkalemia if
-renal failure
-adrenocortical insufficiency
-massive deep muscle injury
*****K is released from damaged cells
Hypokalemia if
-vomiting, diarrhea
-GI suction –> dead tissue
-IV without K supplement
-lost through wound
What can infections do to partial thickness wounds?
make them become full thickness wounds!
INFECTION IS MEJOR THING DURING ACUTE PHASE
Signs and symptoms of infection from burns (AP)
What kind of bacteria usually cause sepsis?
-hypo/hyper thermia
-increased heart- and respiratory rate
-low BP
-low urine output
Usualy G- bacteria –> get cultures and lactate level
Complications during acute phase: cardiovascular and pulmonary
-same as emergent phase
-new stuff could happen though
Complications: Neurologic system (AP)
Delerium
-more so at night
-mostly in old ppl
-usually transient
-complications and sequelae can last for years
Complicatios: endocrine system (AP)
Increased blood glucose levels
-increased mobilization of glycogen stores
-gluconeogenesis
Increased insulin production
-insulin effectiveness decreased due to insulin sensitivity
Hyperglycemia may also be result of high cal intake need –> fucks up wound healing
Nurse management: Excision and grafting (AP)
Cultured epithelial autographs (CEAs)
-grown from biopsies obtained from the patient’s unburned skin
-used in patients with extensive burns and/or limited skin for harvesting
nurse management: nutrition (AP)
caloric needs should be calculated by dietitian
high protein and carbs
antioxidant protocol might be good
monitor labs
weekly weigh ins
Rehabilitation phase: starts when…
wounds have nearly healed
patient is engaging in some level of self care
Rehabilitation phase: Pathophysiologic changes
Heal either by spontaneous re-epithelialization or by skin grafting
Layers of karatinocytes start rebuilding the tissue structure
Collagen fibers add strength to weakened areas
Rehab phase complication: skin and joint contractures
most common issues
develops bc shortening of scar tissue in flexor tissues of joint
Proper positioning, splinting, and exercise needed to minimize contractures
Why are old people at risk of injury?
unsteady gait
limited eyesight
decreased hearing
skin is drier and more wrinkled
thinner dermis –> reduced bloodflow
Emotional needs of patient
assess circumstances of burn injury
watch for survivor’s guilt, fear of dying, and frustration
new fears may occur in early recovery –> self esteem may be low
sexuality may be a thing
how to tend to emotional needs of patient and fam and caregiver?
address spiritual and cultural needs
suggest caregiver and patient support groups
Potential needs of nursing staff caring for a burn patient
might be hard to cope with deformities of burn
ongoing support services or debriefings could be helpful
self care!
