Ch. 32: Burns Part 2 Flashcards
What are 5 steps for nursing actions of wound care?
- Pre-medicate as prescribed
- Remove previous dressings
- Assess for odors, draining, or discharge
- Cleanse wound as prescribed
- Assist with debridement
What medication may we give to pre-medicate?
- Analgesics
2. Hydroxyzine or diphenhydramine for pruritis
In assist with debridement, what needs to be done?
Provide hydrotherapy to cleanse the wound–use once or twice a day for up to 20 min
- use mild soap/detergent to gently wash burns, then rinse with room temp water
- encourage active ROM during hydrotherapy
- Monitor for cold stress and hypothermia
What are the 3 types of biological skin coverings?
Allograft
Xenograft
Synthetic skin coverings
Biological skin coverings may be used to promote healing of _____. What does it require?
Large burns; requires repeated surgical application
Biological: skin from human cadavers that is used for partial and full thickness burn wounds
Allograft
Biological: Obtained from animals, such as pigs, for partial thickness burn wounds
Xenograft
Biological: Used for partial thickness burn wounds
Synthetic skin covering
Permanent skin coverings may be the treatment of choice for burns covering _______
Large areas of the body
What are the 2 types of permanent skin coverings?
Autograft (3 types of autografts)
Artificial skin
What is an autograft?
Clients skin
Permeant skin covering: What are the 3 types of autografts?
Sheet graft
Mesh graft
Cultured epithelium
Permanent skin covering-Autografts
Sheet of skin used to cover the wound
Sheet graft
Permanent skin covering-Autograft
Sheet of skin placed in a mesher so skin graft has small slits in it; allows grafts to cover larger areas of burn wound
Mesh graft
Permanent skin covering-Autograft
Epithelial cells cultured for use when grafting sites are limited
Cultured epithelium
Permanent skin covering:Synthetic product that is used for partial and full thickness burn wounds. Healing slower or faster?
Artificial skin; healing is faster
Skin coverings: Should graft site be movable?
No, maintain immobilization of the graft site
Skin coverings: Should we elevate extremity or let it relax in normal body alignment?
Elevate it
What are some signs of infection to a skin graft?
- Discoloration of unburned skin surrounding burn wound
- Green color to SQ fat
- Degeneration of granulation tissue
- Development of subeschar hemorrhage
- Hyperventilation
- Unstable body temp
What should we instruct the client about their skin covering?
Keep extremity ELEVATED
Report signs of infection
Complications: Inhalation injury- Direct thermal injury
Occurs with burns to ____.
Can be delayed ____ hrs.
Findings?
Nursing actions?
Face and lips
24-48 hours
Wheezing, increased secretions, hoarseness, wet crackles in lungs, singed nasal hairs, laryngeal edema, carbonaceous secretion
Maintain airway and ventilation; proved 100% o2 if prescribed
Complications: Inhalation injury-Carbon monoxide injury
Occurs?
Findings?
Nursing actions?
Incident took place in an enclosed area
Findings: Mucosal erythema and edema, followed by sloughing of the mucosa
Maintain airway and ventilation; provide 100% o2 if prescribed
Complications: Shock/systemic sepsis
What do we administer?
What do we monitor?
What do we assess?
Administer: IV crystalloid solutions for first 24 hours, followed by colloid solutions
Monitor: I&O, Labs, VS
Assess: Sensorium confusion; Cap refil
Complications: Pulmonary problems
How do maintain airway?
Adminster?
Maintain airway via intubation, sometimes tracheostomy
Administer oxygen as prescried
