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Complex Care > Care of burn patient > Flashcards

Care of burn patient Flashcards

1
Q

What do burns that are less than 20% TBSA produce?

A

They produce a localized tissue response

If patient if very young or old, or has comorbidities then they may have more than localized tissue response

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2
Q

What occurs in the body if burns are greater than 20% TBSA?

A

Major injury
All body systems affected d/t cytokine and other mediators released into the systemic circulation
Produces Botha systemic and localized response

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3
Q

How you do evaluate the size of a burn/TBSA?

A
  1. Rule of nine
  2. Lund Browder
  3. Rule of palms
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4
Q

What is the rule of nines?

A

Used to measure first and second degree burns
Hand: 1.5%
Full arm (front and back): 9%
Full head: 9%
Front of chest/stomach: chest- 9%, stomach 9% full - 18%
Back of chest/stomach: 18%
Full leg (front and back): 18%

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5
Q

What is the Lund Browder?

A

Used in burn centers for more exact formulas to assess TBSA

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6
Q

What is the rule of palms?

A

Really fast

Used the palm of the patient and counts how many of the patients palms the burn is

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7
Q

What does A, B, C, D, E, F stand for? What is it associated with?

A

Primary survey

a: airway
b: breathing
c: circulation
d: disability
ex: exposure and examine
f: fluid resuscitation

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8
Q

Primary survey - A: airway

A

Airway and C-spine stabilization

  1. Maintain a patent airway which may require intubation
  2. Check if patient has an advanced directive before intubating
  3. Always immobile the spinal until it is for sure that patient does not have a cervical spine injury
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9
Q

Primary survey - B: breathing

A
  1. Give 100% FiO2 via an oxygen mask

2. Assess for any burns that may impede blood flow like to the neck which could cause edema and close off the airway

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10
Q

Primary survey - C: Circulation

A
  1. Elevate the extremities
  2. Remove any tight clothing or jewelry
  3. PULSE CHECK especially with circumferential and electrical burns
  4. Assess if they are warm, cool, diaphoretic
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11
Q

Primary survey - D: disability

A

neuro exam

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12
Q

Primary survey - EX: expose and examine

A

extent and depth of wound of possible associate trauma

if patient has trauma, go to the trauma ICU first to stabilize and then go to burn unit once stabilized

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13
Q

Primary survey - Fluid resuscitation

A
  1. Minimum of 2 large bore IV
  2. Start lactated ringers

**huge shift of fluid with burns so it is important to give the fluids quickly

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14
Q

What does the secondary survey include?

A
  1. Circumstances like time, cause, chemicals
  2. Medical hx, medications, allergies, vaccinations, last fluid and food intake
  3. Head to toe exam
  4. Calculate the depth and TBSA percentage of the burn
  5. Tetanus, pregnancy status
  6. Labs tests: CBC, CMP, PT/aPTT, UA, cultures
  7. ABG and carboxyhemoglobin level for suspected inhalation injury
  8. EKG and CK-MG/trop for electrical injury
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15
Q

What interventions are started in the secondary survey?

A
  1. Maintain normal thermic body temperature
  2. Pain medications (IV narcotic)
  3. Cover the wound with a dry, clean, and warm sheet
  4. Fluid resuscitation calculation and IV fluid rate adjustment
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16
Q

What is the key take aways from the secondary survey?

A
  1. Keep normal thermic temp
  2. Pain medications
  3. If suspect inhalation injury –> get resps labs (carboxyhemoglobin and ABG)
  4. 12 lead ECG and CK-MB/trop if electrical injury
  5. Figure out TBSA and give fluids based on that percentage
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17
Q

What are the phases of interventions in a burn injury?

A
  1. Emergent
  2. Acute
  3. Rehabilitation
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18
Q

What occurs in the emergent phase? How long is it?

A
  1. injury just happened

first 48 hours

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19
Q

What occurs in the acute phase? How long is it?

A
  1. Day to day care including daily wound care, specialty consult, possible
    surgery, deciding how long it will take the patient to heal, if they need plastic surgery, if they need speech therapy

Weeks to months

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20
Q

What occurs in the rehabilitation phase? How long is it?

A
  1. Once the patient’s wound is heal and closed.
  2. Skin may tear because it is not as strong as it once was while in this phase
  3. Can be done at home, rehab hospital, or hybrid

More than 2-10 years

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21
Q

What is burn shock? When does it occur?

A

Hypovolemic and disruptive shock

  1. Massive fluid loss externally and heavy protein loss
  2. Significant interstitial fluid shift –> wound edema and third spacing

Occurs right after a burn within 20 minutes

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22
Q

What is the pathology behind burn shock?

A
  1. Burn
  2. Increased capillary permeability
  3. Decreased vascular volume and edema
  4. Increased hematocrit and decreased blood volume
  5. Increased blood viscosity –> higher risk for clots
  6. Increased peripheral resistance
  7. Burn shock
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23
Q

What happens to electrolytes and cellular components during burn shock?

A
  1. Potassium moves from inside the cell to outside the cell
  2. Sodium moves from outside the cell to inside the cell
  3. Increased concentration of RBC d/t fluid loss
  4. Albumin is lost –> edema
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24
Q

What occurs to the body with the early stage of burn shock?

A

Less than 48 hours

Body is trying to send blood to vital organs

  1. Increased HR
  2. Increased hematocrit
  3. Decreased CO
  4. Decrease SVR
  5. Decreased SvO2
  6. Edema (concerned about compartment syndrome so check if pulses are equal)
  7. Kidney damage (monitor UO and color b/c myoglobin from muscle breakdown can occlude tubules)
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25
Q

What occurs to the body with the after first 48 hours of burn shock? What do they need?

A
  1. Hypermetabolic (HR remains high)
  2. Muscle breakdown
  3. Hyperglycemia
  4. Clot formation

NEED

  1. More pain medications because they are burning through them
  2. More calories and usually need feeding tube for a little
  3. More infection control because lost their skin as a protective barrier
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26
Q

Why are large fluid requirements need in a burn patient?

A

The patient is losing a lot of fluid so we must replace them to maintain tissue perfusion

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27
Q

What are the consequences of under-resuscitation?

A

Overwhelming acidosis (Lactic acidosis)

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28
Q

What are the consequences of over-resuscitation?

A

lung injury (flooding the lungs), ARDS, compartment syndrome

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29
Q

How do you ensure that are you not over or under resuscitating?

A

Use the parkland formula

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30
Q

What are the EMS guidelines for resuscitation for burns >30%?

A

Under 5: 125ml LR/hour
6-13: 250ml LR/hour
over 14: 500ml LR/hour

** won’t over do it because get to hospital very quickly

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31
Q

Do these patients need a foley when they get to the ED?

A

YES

32
Q

What is the parkland fluid resuscitation? Who is it used for? How long do you give this fluid for? What is the UO goal?

A

Adults over age 14

4ml LR x TBSA x kg

Give 1/2 of fluid calculated in the first 8 hours and the second half over the next 16 hours

UOP goal is 0.5ml/kg/hour or 30-50 ml/hr

33
Q

How do you monitor if that patient is getting enough fluid resuscitation while using the parkland formula? How do you fix this if not enough perfusion?

A

If UOP is out of range for 2 consecutive hours

Increase or decreased fluids by 20% or 1/3

Can also look at chest xray or pulses to see if they are getting flooded with fluid

34
Q

What is the parkland formula for a electrical injury? What is the UO goal? Why is it more?

A

4ml LR x TBSA x kg

UO: 75-150ml/hr but many need to increase up to 1-1.5ml/kg/hr to clear urine if urine is not getting more clear within 4 hours

UO goal is increased because you need to protect the kidneys. With electrical injury there is an increased risk for acute kidney injury d/t muscle damage and breakdown –> myoglobin clogging the kidneys. Kidneys are being protected if urine goes from dark red to pink to clear.

35
Q

What are the overall goals of care for a burn patient?

A
  1. Adequate gas exchange and respiratory patten
  2. Adequate tissue and organ perfusion
  3. Prevent extension of injury: burn can convert into a deep tissue injury (secondary injury) especially in the first 24 hours if not given proper fluid resuscitation
36
Q

When assessing the airway on a burn patient, what are you looking for?

A
  1. Facial burns, inhalation injury or burn >25%
  2. Assess the sputum for carbon, soot, dry/thick
  3. Monitor for pulmonary edema, atelectasis, pneumonia, and ARDS
37
Q

What interventions is the nurse going to do for the airway in a burn patient?

A
  1. Bronchoscopy to see into the airway
  2. Humidified O2 to keep airway clear
  3. 100% FiO2 to remove carbon monoxide
  4. Monitor Carboxyhemoglobin
  5. Agressive pulmonary interventions such as HOB elevated, turn them, possible albuterol
38
Q

What is the nurse monitoring/concerned for regarding circulation in a burn patient?

A
  1. Hypovolemia shock
  2. K+ released –> monitor K+ and Ca+ and treat dysrhythmias
  3. Decreased CO –> complications to all organs
  4. IV access –> central line with CLABSI bundle
  5. Hemodynamic markers (SV: 70% or SVV <13-15)
  6. UO >30-50ml/hr and look at color to ensure not concentrated
  7. ABG: acidosis (lactate <2 and base deficit to keep pH balanced)
39
Q

Care during the emergent phase consists of..

A
  1. Pain management
  2. Sedation/anxiolytic
  3. GI symptom management
  4. Thermal control
  5. Infection control
  6. Building rapport right away
  7. Monitoring for compartment syndrome
40
Q

How do you manage pain during the emergent phase?

A

Small frequent doses or infusion of pain medication

41
Q

How do you manage their GI symptoms during the emergent phase?

A
  1. NG to prevent and manage an ileus (blood is being sent to vital organ instead of GI so stops working) and manage intubated patients
  2. Early tube feedings within 24 hours because they are in a hyper metabolic state and need a lot of calories
  3. Curling’s ulcer/stress ulcer with H2 blocker, PPI, or cytoprotective
42
Q

How dayyou manage thermal control during the emergent phase?

A
  1. Warming blankets
  2. High room temp
  3. Warming lamps

** these patients cannot maintain their own temp **

43
Q

How do you provide infection control during the emergent phase?

A
  1. Gown and gloves for contact during all wound care and at all times for a patient for more than 20% burn
  2. Topicals
  3. Own vent system separate from the rest of hospital

** patients are at risk for sepsis because they have lost their skin protective barrier **

44
Q

When is compartment syndrome common? What kind of assessment do they need often? How do you treat it?

A
  1. Full thickness circumferential burns, electrical burns or patient with large fluid resuscitation needs
  2. Neurovasuclar assessment including sensation/parasthesias, pulse checks every 15-60 minutes, cap refill, general feeling of the limb (looking for increased pressure/tightness)
  3. Eschatotomy or Fasciotomy
45
Q

What compartment pressures need treatment with either a Escharotomy or Fasciotomy? What are other s/s of compartment syndrome that would indicate treatment is needed?

A
  1. Compartment pressure >30mmHg
  2. Loss/decrease sensation in extremity
  3. Loss of dopplerable pulses
  4. Leg feels so tight that you can’t squeeze it
46
Q

What is a Escharotomy or Fasciotomy? Where is it preformed? What are the goals?

A
  1. Cuts through the eschar or fascia depending on how deep the burn is
  2. Preformed at the bedside or OR
  3. End result is return of blood flow through/to that part of the body indicated by pulses return, skin starts to pink up, patient can move that part of their body again
47
Q

What is eschar? What is a problem that is could cause?

A
  1. Inelastic burnt/dead tissue
  2. If eschar is on the chest, then a patient may not be able to breath will because their skin won’t allow their lungs to expand and the patient could end up with barotrauma or a pneumothorax if escharotomy is not preformed
48
Q

What is fascia? Is a fasciotomy deeper than an escharotomy?

A
  1. Band/sheet of connective tissue beneath the skin and attaches, stabilizes, ensures and separates muscles and other organs
  2. Yes a fasciotomy is deeper
49
Q

How long is the emergent phase?

A

First 48 hours

Can go up to 72 is resuscitation is complicated and lasts longer

50
Q

What are the main goals of the emergent phase?

A
  1. Perfusion
  2. Effective ventilation/oxygenation
  3. Pain management and emotional care
  4. Nutrition (start it!!)
  5. Fluid resuscitation***
  6. Prevention of hypothermia

**Wound care is not the priority, only trying to stabilize patient **

51
Q

What are the main things going on in the acute phase? What are the goals?

A
  1. Fluid balance
  2. Edema management
  3. Promote wound closure
  4. Infection prevention
  5. Pain control
  6. Adequate nutrition
  7. Prevent complications
52
Q

When does wound care become a priority?

A

When the patient is stable

53
Q

What are some options for wound care in the acute phase?

A
  1. Antimicrobial topical agents (bacitracin, silver sulfaf=diazine, sulfamylon (cream/soak))
  2. Collagenase enzymatic debridement (chemical debridement)
  3. Medical grade honey
  4. Antifungal - nystatin
  5. Hydrotherapy
  6. Debridement
54
Q

What is hydrotherapy? What is a comfort consideration that should be taken into account?

A

Uses water to loosen dead tissue and help with the removal of tissue and agents
Prevent hypothermia with giant heat lamps

55
Q

What is debridement? How is it done?

A

Wash off any topicals, take off any dead skin that will come off so new skin has a chance to grow

  1. Mechanical
  2. Enzymatic
  3. Surgical
56
Q

What is an RN responsibility regarding wound care?

A
  1. Careful monitoring and planning
  2. High dose medication
  3. Competency requirement because giving narcotics like fentanyl and ketamine, anxiolytics like benzos and dissociative anesthetics
57
Q

What are the types of grafts that can be used?

A
  1. Autograft - patients own skin
  2. Allograft - cadaver skin and used as a temporary covering to create a good wound bed
  3. Xenograft - pig skin and used as a temporary covering for burns that don’t require a skin graft to provide relief while their wound is helping and it comes off like a scab
  4. CEA - grown skin
58
Q

What is CEA? When is it used?

A

Cultured epithelial cells
Take a small portion of the skin –> send to lab –> skin is grown in 2 weeks and comes back in little squares
Used when tissue can’t be take from the patient or in TBSA >85%
Expensive

59
Q

What is the difference between a sheet graft and a mesh graft?

A

Sheet is a continuous piece and there is a better cosmetic outcome so it is used for the face, hands, neck, feet, and joints

Mesh graft is where holds are put into the skin and it is stretched so it can cover a much larger area. When it heals, looks like lace

60
Q

What considerations should be taken for the graft site?

A
  1. No pressure on site
  2. Roll of any bubbles of air and fluid
  3. Keep edges moist
  4. Observe for “take” usually occurs in 5-6 days
61
Q

What do you do for the donor site?

A
  1. Pain management
  2. Moist to dry wound healing
  3. Thin dressing
  4. Heals in 7-14 days
62
Q

What is an issue with pain management with burn patients? When should they be given more medication? What is a misconception regarding pain meds?

A

The patient is rapidly metabolizing the medications so they require higher and more frequent doses
Give more medication when they go to therapy and procedures and when they have a new donor site and new wounds
Misconception is that they are drug seeking and addicted

63
Q

What medications are be given to a burn patient?

A
  1. Anxiety (bend, antidepressants)
  2. B-blcokers (to reduce HR d/t hyper metabolic state. Propranolol or if patient has asthma or inhalation injury metoprolol)
  3. Anabolic steroid (oxandrolone used for increase muscle protein metabolism d/t muscle breakdown, helps later on)
  4. GH
64
Q

What should you assess before giving medication in patients?

A

History of substances like alcohol, marijuana, amphetamines
Could change which medication are used
With marijuana, could need an increase in pain medication because body is more tolerant

65
Q

What are nutritional concerns r/t burn patients?

A
  1. Hyper-metabolic state for more that 2 years after the injury
  2. TBSA > 40 has 2x resting metabolic rate so they consume more nutrients and metabolize drugs faster
  3. Malnutrition (can make grafts fall off)
  4. High dose of vitamin C to decrease fluid needs and increase healing
  5. Multivitamin, folic acid, zinc
  6. Protein and calorie rich diet (2-3gram protein/kg every 24 hours)
  7. Enteral nutrition preferred over TPN (high carb, low fat and can use 24 hour and hourly goals)
66
Q

What are some wound infections that can occur? What do you watch for? What are concerned of infections? What do you do to treat?

A
  1. Cellulitis
  2. Assess for erythema, edema, increased pain
  3. Will prevent wound from healing
  4. Treat with debridement and IV antibiotics if s/s
67
Q

What occurs in the rehab phase? What are the goals of this phase?

A
  1. Wound is closed
  2. 80% tissue strength so high risk for tissue damage
  3. Itching
  4. Temperature regulation issues so dress appropriately
  5. Lasts years

Goals: mobility, maximal function, effective coping, role resumption/adaption (own self care)

68
Q

When does mobility start? What does mobility look like? What is the goal of mobility?

A

Starts first day in hospital

  1. ROM
  2. Positioning - splinting position of greatest function, put pillows under joints to keep extremities in extended positions and no pillow under neck to keep to stretched

Goal is to prevent contra cures especially over joints and neck

69
Q

What can you do for the skin in the rehab phase? What are some barriers?

A
  1. Skin care/prevention
  2. Scar massage
  3. Scar compression (elastic wrap, pressure garments, tight fitting, skin stretch)
  4. ROM

Might be cosmetic concerns and compliance concerns

70
Q

What does laser and ablation therapy do? What are complications?

A

Laser: takes the surface off of old scar and creates new wound with new healing
Ablation removes target tissue

New remodeling

Complications are dry, peeling, itching, delayed hypo pigmentation, and infection

71
Q

What are some psych concerns in burn patients?

A
  1. Body image distress/disorder (scars, graft leaves marks, pressure garments in public)
  2. Depression of not being able to do everything as before
  3. Shame
  4. Guilt d/t fault, death of others in accident, family finances devoted by medical costs
  5. Return to previous activites
72
Q

Fish skin graft

A

Used where allograft or Xeonograft supply is limited

73
Q

Spray on skin

A

Treats burns with a slurry of patients own skin cells. Spays them onto the body

74
Q

In emergent phase, what happens the the water, plasma proteins, and sodium?

A

All of leave the plasma space and move into interstitial space

75
Q

What occurs regarding to capillary permeability r/t shock?

A

Capillary pores enlarge or integrity of capillary wall is damages –> increase permeability –> plasma proteins and other particles leak into interstitial space –> accumulation of interstitial fluid –> swelling

76
Q

What lab work can be expected in an initial burn?

A
  1. Low albumin

2. High HCT (going to look elevated because there is less plasma - HCT is a concentration level)

Complex Care (22 decks)

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