Ch. 35

Question 1

two major layers: (1) epidermis and (2) dermis
Epidermis
Dermis
Hypodermis

Answer 1

ANATOMY AND FUNCTIONS OF THE SKIN

Question 2

Outermost layer of the epidermisThe epidermis is composed of dead, cornified cellsc that act as a tough protective barrier against the environment. It serves as a barrier to bacteria and moisture loss.
five epidermal layers regenerates every 2 to 3 weeks

Answer 2

Epidermis

Question 3

second, thicker layer, the dermis regenerates continuously
composed primarily of connective tissue and collagenous fiber bundles made from fibroblasts, provides nutrition support to the epidermis.
dermis contains blood vessels; sweat and sebaceous glands; hair follicles; nerves to the skin and capillaries that nourish the avascular epidermis; and sensory fibers that detect pain, touch, and temperature. Mast cells in the connective tissue perform the functions of secretion, phagocytosis, and production of fibroblasts.

Answer 3

Dermis

Question 4

is beneath the dermis and contains fat, smooth muscle, and areolar tissues.
acts as a heat insulator, shock absorber, and nutrition depot.
skin provides functions crucial to human survival, including maintenance of body temperature; a barrier to evaporative water loss; metabolic activity (vitamin D production); immunologic protection by preventing microbes from entering the body; protection against the environment through the sensations of touch, pressure, and pain; and overall cosmetic appearance.

Answer 4

Hypodermis

Question 5

burn injury results in tissue loss or damage. Injury to tissue can be caused by exposure to thermal, electrical, chemical, or radiation sources.
temperature or causticity of the burning agent and duration of tissue contact with the source determine the extent of tissue injury.
Tissue damage is caused by enzyme malfunction and denaturation of proteins. Prolonged exposure or higher temperatures can lead to cell necrosis and a process known as protein coagulation. The areas extending outward from this central area of injury sustain various degrees of damage and are identified by zones of injury
Zones of Injury

Answer 5

PATHOPHYSIOLOGY AND ETIOLOGY OF BURN INJURY

Question 6

Three concentric zones are present in burn injury: (1) zone of coagulation, (2) zone of stasis, and (3) zone of hyperemia central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the site of least severe damage. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.
area is surrounded by the zone of stasis, which is characterized by impaired circulation that can lead to cessation of blood flow caused by a pronounced inflammatory reaction.
Area is potentially salvageable; however, local or systemic factors can convert it into a full-thickness injury.
factors that can lead to deeper wound conversion are toxic mediators of the inflammatory process, infection, inappropriate volume resuscitation, malnutrition, chronic illness, or the local wound care provided. It may take 48 to 72 hours to determine the full extent of injury in this area. The outermost area, the zone of hyperemia, has vasodilation and increased blood flow but minimal cell involvement. Early spontaneous recovery can occur in this area.

Answer 6

Zones of Injury

Question 7

A quick and easy method is the rule of nines (or Berkow formula), which often is used in the prehospital setting for initial triage of a patient with burns
In this method, the adult body is divided into different surface areas of 9% per area.

Answer 7

Size of injury

Question 8

The depth of the burn is defined by how much of the skin’s two layers are destroyed by the heat source.
Burns are classified as superficial, partial-thickness, deep-dermal partial-thickness, or full-thickness burns. These descriptions are based on the surface appearance of the wound.
Superficial burns include first-degree burns and are limited to the epidermis.
Partial-thickness burns include various stages of second-degree burns, and full-thickness burns include third-degree burns. Fourth-degree burns extend through all skin layers and extend into muscle, tendon, and bone.
Wound assessment involves recognition of the depth of injury and the size of burn, and it can be challenging even for experienced caregivers.
A superficial (first-degree) burn involves only the first two or three of the five layers of the epidermis.
Erythema and mild discomfort characterize superficial partial-thickness wounds. Pain, the chief symptom, usually resolves in 48 to 72 hours.
These wounds usually heal in 2 to 7 days and do not require medical intervention aside from pain relief, management of pruritus (itching), and oral fluids. Swelling can be a common complication that may require intervention. Superficial burns are not included in the calculation of percent burn.
A partial-thickness (second-degree) burn involves all the epidermis and part of the underlying dermis. These burns usually are caused by brief contact with flames, hot liquid, or exposure to dilute chemicals
A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. These burns blanch painfully.
microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid lifts off the thin, damaged epidermis, causing blister formation.
Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. These burns often result from contact with hot liquids or solids or with intense radiant energy. A deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.
wounds have a prolonged healing time. They can heal spontaneously as the epidermal elements germinate and migrate until the epidermal surface is restored, or they may require a skin substitute or surgical excision and grafting for wound closure. This process of healing by epithelialization can take up to 6 weeks.
Left untreated, these wounds can heal primarily with unstable epithelium, late hypertrophic scarring, and marked contracture formation. Partial-thickness injuries can become full-thickness injuries if they become infected, if blood supply is diminished, or if further trauma occurs to the site. The treatment of choice is surgical excision and skin grafting.
A full-thickness (third-degree) burn involves destruction of all the layers of the skin down to and including the subcutaneous fat subcutaneous tissue is composed of adipose tissue, includes the hair follicles and sweat glands, and is poorly vascularized. A full-thickness burn appears pale white or charred, red or brown, and leathery.
surface of the burn may be dry, and if the skin is broken, fat may be exposed
All other full-thickness wounds require skin grafting for closure. Extensive full-thickness wounds leave the patient extremely susceptible to infections, fluid and electrolyte imbalances, alterations in thermoregulation, and metabolic disturbances.
It is important to identify the depth of injury for appropriate treatment.
The TBSA of the burn is calculated at the same time that assessment for wound depth occurs. This calculation provides the basis for determining the amount of fluid required for treatment.

Answer 8

Depth of burn injury

Question 9

Thermal Burns
Electrical Burns
Chemical Burns
Radiation Burns

Answer 9

Types of Injury

Question 10

most common type of burn is a thermal burn caused by steam, scalds, contact with heat, or fire.
Contact with hot foods (burns)length of time the hot object is in contact with the skin determines the depth of injury.
Non food-related thermal burns can occur from fireworks, irons, curling irons, campfires, and fire pits in young children.
Burns associated with the use of lighters, lighter fluid, fire, fire-crackers, and gasoline are seen in adolescents.
Contact and flame burns tend to be deep-dermal or full-thickness injuries.

Answer 10

Thermal Burns

Question 11

These accidents occur as a result of insertion of an object into an outlet or by biting or sucking on an electrical cord. These burns can lead to tissue destruction and contracture formation.
Common situations that may increase the risk for electrical injuries include occupational exposure and accidents involving household current.

Answer 11

Electrical Burns

Question 12

Acid and alkali agents cause chemical burns. Alkali burns commonly result in more severe injuries compared with acid burns.
Acid and alkali agents are found in many household and industrial substances
Chemical burns most commonly occur in the domestic setting as a result of nonintentional exposure to household chemicals
The concentration of the chemical agent and the duration of exposure are the key factors that determine the extent and depth of damage.
Progression of injury from chemical burns to their complete depth may be delayed, and the full extent of the injury may not be apparent until 48 hours after injury. Time must not be wasted in looking for a specific neutralizing agent, because the injury is related directly to the concentration of the chemical and the duration of the exposure, and the heat of neutralization can extend the injury.

Answer 12

Chemical Burns

Question 13

usually are localized and indicate high radiation doses to the affected area.
may appear identical to thermal burns.
The major difference is the time between exposure and clinical manifestation; it can be days to weeks, depending on the level of the radiation dose.

Answer 13

Radiation Burns

Question 14

The first priority of emergency burn care is to secure and protect the airway.
Patients with HbCO level elevated greater than 10% and arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FIO2) ratio less than 200 have a high probability of needing respiratory support.
All patients with major burns or suspected inhalation injury are initially administered 100% oxygen. The nurse should continue to observe the patient for clinical manifestations of impaired oxygenation such as tachypnea, agitation, anxiety, and upper airway obstruction (e.g., hoarseness, stridor, wheezing). Early intubation may be lifesaving in a patient who has an inhalation injury, because it may be impossible to perform this procedure later, when edema has obstructed the larynx. The need for frequent blood sampling and the benefit of continuous blood pressure monitoring may necessitate placement of an arterial line.

Answer 14

Airway Management

Question 15

Circumferential, full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance.
Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.
Clinical manifestations of chest wall restriction include rapid, shallow respirations; poor chest wall excursion; and severe agitation. Arterial blood gas analysis reveals a decrease in oxygen tension and an increasing arterial partial pressure of carbon dioxide (PaCO2) level. Patients receiving mechanical ventilation have increasing peak airway pressure values
Escharotomies (burn eschar incisions) may be needed immediately to increase compliance and for improved ventilation.

Answer 15

Respiratory Management

Question 16

The extent of TBSA of the burn is calculated for estimation of fluid resuscitation requirements
Burn shock is caused by loss of fluid from the vascular compartment into the area of injury resulting in hypovolemia. The larger the percentage of burn area, the greater is the potential for development of shock. Lactated Ringer solution is infused through a large-bore cannula in a peripheral vein.
can restore cardiac output to normal in most patients. It is preferred over normal saline because it most closely matches extracellular fluid.
Continuous monitoring with electrocardiograms (ECGs) should be used in patients with serious thermal burn injury and in the presence of electrical burns, inhalation injury, or associated traumatic injury.

Answer 16

Circulatory Management

Question 17

Burn injuries greater than 20% of TBSA can result in burn shock.
Shock is defined as inadequate cellular perfusion. Significant burn injury results in hypovolemic shock and tissue trauma. Both cause the production and release of several local and systemic mediators.
The first component of burn shock is hypovolemic shock. At the cellular level, the burning agent produces dilation of the capillaries and small vessels, increasing the capillary permeability.
Edema occurs locally in the burn wound and systemically in unburned tissues.
Edema formation is unique to thermal injury.
In addition to leaking capillaries, local and systemic mediators cause edema and the cardiovascular problems seen in patients with burns. These mediators include histamine, prostaglandins, kinins, and oxygen radicals, and they increase arteriolar vasodilation.
The intravascular fluid changes combined with the action of inflammatory mediators and vasoconstriction mediators result in hemodynamic consequences in patients with burns. The hemodynamic alterations include decreased myocardial contractility and cardiac output despite adequate volume resuscitation, increased systemic vascular resistance (SVR),
The nurse must assess the patient’s fluid status and response to resuscitation to obtain the optimal response.

Answer 17

Pathophysiology of Burn Shock

Question 18

If fluid resuscitation is inadequate, AKI may occur. In the emergency department, an indwelling urinary catheter should be placed for burns greater than 20% of TBSA to monitor urine output and the effectiveness of fluid resuscitation.

Answer 18

Kidney Management

Question 19

Patients with burns of greater than 20% of TBSA are prone to gastric dilation as a result of paralytic ileus. Nasogastric or orogastric tubes are placed in these patients to prevent abdominal distention, emesis, and potential aspiration. This decrease in gastrointestinal (GI) function is caused by the effects of hypovolemia and the neurologic and endocrine response to injury.
Enteral nutrition should be started as soon as possible.

Answer 19

Gastrointestinal System Management

Question 20

Edema formation may cause neurovascular compromise to the extremities; frequent assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation. Arterial circulation is at greatest risk with circumferential burns.
If not corrected, reduced arterial flow causes ischemia and necrosis.
If escharotomy is required before the patient is transferred to a burn center, consultation with the receiving physician is advised.

Answer 20

Extremity Pulse Assessment

Question 21

Initial laboratory studies include complete blood count, electrolytes, blood urea nitrogen (BUN), creatinine, urinalysis, glucose, and blood screening. Special situations such as inhalation injury warrant arterial blood gas measurements, HbCO level determination, cultures, alcohol and drug screens, and cyanide levels.
A baseline assessment of nutrition status, including albumin and prealbumin, is helpful in monitoring future nutrition needs. Also, creatinine kinase, urinalysis, and urine myoglobin are good indicators of rhabdomyolysis seen in the setting of electrical burn injuries. An ECG is obtained for all patients with electrical burns or preexisting heart disease. Serum lactate is also another good inflammatory marker indicating burn severity.

Answer 21

Laboratory Assessment

Question 22

After wounds have been assessed, topical antimicrobial therapy is not a priority during emergency care. However, the wounds must be covered with clean, dry dressings or sheets. Every attempt must be made to keep the patient warm because of the high risk of hypothermia. The administration of tetanus prophylaxis is recommended for all burns covering more than 10% of the TBSA and for patients with an unknown immunization history.

Answer 22

Wound Care.

Question 23

can occur in the presence or absence of cutaneous injury. Inhalation injuries are strongly associated with burns sustained in a closed or confined space, and they are associated with increased mortality.6 Inhalation injury can occur in three basic forms, alone or in combination: carbon monoxide poisoning, direct heat injury, and chemical damage. The three types of inhalation injury are carbon monoxide poisoning, upper airway injury, and lower airway injury.
Immediate lifesaving measures in patients with burns include management of the airway.
Inhalation injury increases the patient’s risk of developing pneumonia and acute respiratory distress syndrome (ARDS). Management of ARDS necessitates mechanical ventilatory support and, in extreme cases, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation.
Carbon Monoxide Poisoning
Upper Airway Injury
Lower Airway Injury

Answer 23

Inhalation Injury

Question 24

the leading cause of death in persons found dead at the scene of a fire who have few or no cutaneous thermal injuries. Carbon monoxide is a colorless, odorless, and tasteless gas.
results in its bonding to available hemoglobin, producing HbCO, which effectively decreases oxygen saturation of hemoglobin.
shortage of oxygen at the tissue level is worsened by a shift to the left of the oxyhemoglobin dissociation curve, reflecting the fact that the oxygen in the hemoglobin is not readily given up to the cells.
Arterial blood gases and oxygen saturation are used to accurately assess the hemoglobin oxygen saturation level.
The major clinical manifestations of severe carbon monoxide poisoning are related to the CNS and the heart. Symptoms associated with carbon monoxide poisoning include headache, dizziness, nausea, vomiting, dyspnea, and confusion.
Carbon monoxide poisoning may lead to myocardial ischemia, cardiac dysfunction, and CNS complications caused by reduced oxygen delivery and the already compromised circulatory system.
The treatment of choice for carbon monoxide poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation.

Answer 24

Carbon Monoxide Poisoning

Question 25

Burns of the upper respiratory tract include burns involving the pharynx, larynx, glottis, trachea, and larger bronchi. Injuries are caused by direct heat or by chemical inflammation and necrosis.
Respiratory injury is most often confined to the upper airway.
Heat damage may be severe enough to cause upper airway obstruction at any time, beginning from the moment of injury through the resuscitation period.
Caution is needed for patients with severe hypovolemia, because supraglottic edema may be delayed until fluid resuscitation is underway and third spacing occurs.
Patients must be monitored for hoarseness, stridor, audible airflow turbulence, and the production of carbonaceous sputum.
The prediction of an upper airway obstruction is based on consideration of several variables: extent of injury to the face and neck, presence of blisters on or redness of the posterior pharynx, signs of singed nasal hair, increased HbCO levels, increased rate and decreased depth of breathing, hoarseness and stridor (which indicates a significant decrease in the diameter of the airway), increased amount of sputum, and circumstances of the burn event (whether it occurred in an enclosed space or involved superheated gases or steam).
Intubation is recommended whenever airway patency is questionable, rather than delaying intubation until airway obstruction is so severe that intubation becomes a challenge.
priority is given to minimizing airway edema, maintaining pulmonary hygiene, and treating bronchospasm.
Elevating the head of the bed to 30 degrees or higher decreases airway edema.
Therapeutic deep breathing and coughing, early mobility, suctioning, and bronchodilators assist in mobilizing and removing secretions.
Fiberoptic bronchoscopy may be required to remove secretions in some patients. Mechanical ventilatory support is necessary when respiratory fatigue or failure occurs. Precautions to prevent ventilator-associated pneumonia should be implemented to avoid secondary infection.

Answer 25

Upper Airway Injury

Question 26

Heated air rarely causes lower airway injury. If it does, it usually is associated with a higher mortality rate. Lower airway injuries are typically caused by chemical damage to mucosal surfaces.
Historically, the most accurate method of documenting lower airway injury is the ventilation-perfusion lung scan; however, the study is cumbersome and rarely used.
Plain chest radiography and CT scan are faster and more readily available and can also evaluate lower airway injury.
Patients with inhalation injuries are at risk for developing pneumonia and ARDS.
As with upper airway injury management, aggressive pulmonary hygiene, removal of secretions, ventilatory support, and careful fluid resuscitation so as to avoid exacerbating pulmonary edema and ARDS are indicated when caring for patients with burns and lower airway inhalation injuries.

Answer 26

Lower Airway Injury

Question 27

Chemical Burns
Electrical Burns

Answer 27

Nonthermal Burns

Question 28

can be caused by a variety of products. Acids, alkalis, and organic and inorganic compounds cause chemical burns. The acid or base quality determines the injurious nature of a product. The injury is caused by the pH of the product or by the concentration of the product.
Alkali burns of the eyes require continuous irrigation for many hours after the injury.
Treatments for chemical burns vary.
The solution can be placed directly on the wound and gently wiped off. Routine débridement of loose skin should be initiated after tar removal.

Answer 28

Chemical Burns

Question 29

type and voltage of the circuit, resistance, pathway of transmission through the body, and duration of contact are considered in determining the amount of damage sustained.
The use of appropriately insulated equipment that diverts the circuit elsewhere is essential.
Extreme caution must be used in the rescue of victims.
Electricity always travels toward the ground. The body conducts electrical current as a whole, as opposed to the earlier belief that it traveled most quickly through the nerves and circulatory system.
The electrical burn process can result in a profound alteration in acid base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to kidney function. Myoglobin is a normal constituent of muscle.
With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to AKI.
If hemoglobinuria is identified, the clinician should assume that the patient has myoglobinuria and acidosis.
Sodium bicarbonate may be administered to bring the pH level into the normal range, to correct a documented acidosis, or to alkalize urine to promote myoglobin excretion. Diuretics such as mannitol also may be administered to increase renal blood flow and glomerular filtration rate to facilitate myoglobin clearance.18 Sodium bicarbonate infusions and diuretic therapy are called forced alkaline diuresis.
A baseline ECG and myocardial biomarker levels should be obtained while the patient is in the emergency department. The following criteria are used for monitoring the cardiac status of patients with burns: A history of loss of consciousness or cardiac arrest; Documentation of cardiac dysrhythmia at the scene of the accident or in the emergency department
TBSA burns of greater than 20%; Very young age or advanced age; Prior history of heart disease
Other patients with burns may be admitted to nonmonitored settings and observed closely.
Cardiac dysrhythmias must be treated promptly, and a protocol to rule out myocardial infarction must be followed.

Answer 29

Electrical Burns

Question 30

Life-threatening airway and breathing problems, cardiopulmonary instability, and hypovolemia characterize the resuscitation phase, or shock phase. Burn injury affects the structure and function of almost every organ.
The goal of the resuscitation phase is to maintain vital organ function and perfusion. Emergent interventions for inhalation injury, airway management, and hypovolemia are concurrently addressed.

Answer 30

Resuscitation Phase

Question 31

Current resuscitation protocols emphasize fluid delivery rates based on the extent of burn injury and the patient’s weight.
The actual amount of fluid given to any patient must be based on that individual’s response. The goal of fluid resuscitation is to maintain end organ perfusion and avoid fluid overload.
Colloid replacement can increase circulating volume and decrease fluid needs.20 In addition to colloid, maintenance fluids are given to replace evaporative losses, and the amount is adjusted according to the patient’s serum electrolyte levels, urine output, weight, volume status, and clinical assessment.

Answer 31

Fluid Resuscitation

Question 32

Ineffective Kidney Tissue Perfusion
Ineffective Cerebral Tissue Perfusion
Ineffective Peripheral Tissue Perfusion
Ineffective Gastrointestinal Tissue Perfusion

Answer 32

Tissue Perfusion

Question 33

Urinalysis to determine the myoglobin level may be performed soon after burn injury. Myoglobinuria can be detected grossly by the dark, port-wine color of the urine. Myoglobin is extremely toxic to the kidneys and can cause massive tubular destruction.
best treated with rapid fluid administration and forced diuresis with diuretics such as mannitol, an osmotic diuretic.
goal is an hourly urine output that is at least double the general recommendations to flush the kidney tubules
Sodium bicarbonate is sometimes given intravenously to alkalinize the urine and assist in the elimination of heme pigments
Impairment of the renal system may be related to hemoglobinuria, myoglobinuria, hypoperfusion, and hypovolemia. Urinary output must be monitored every hour for the first 48 to 72 hours, and specific gravity values can be used to determine the adequacy of hydration status and renal competency. The urine glucose concentration is monitored, as are urine sodium, creatinine, and BUN levels.
Use of an indwelling urinary catheter is appropriate for the first 48 to 72 hours.
However, leaving the catheter in place may be necessary if perineal burns are involved.
Oliguria may be associated with AKI but is usually related to inadequate fluid resuscitation in patients with burns.
AKI occurs early during resuscitation or late secondary to sepsis
Other signs of kidney failure include increasing creatinine, BUN, phosphorus, and potassium levels; excessive fluid-weight gain; excessive edema; elevated blood pressure; lethargy; and confusion.
The presence of glucose in the urine causes osmotic diuresis - urine output is an unreliable estimate of volume status. Because of the increased loss of fluid through the kidneys, glucosuria may suggest the need for additional fluid beyond the original estimates.

Answer 33

Ineffective Kidney Tissue Perfusion

Question 34

The patient’s neurologic status is assessed frequently during the first few days. Changes may be related to an associated head injury that occurred at the time of burn injury, hypoperfusion related to hypovolemia, hypoxemia associated with inadequate ventilation, carbon monoxide poisoning, or electrolyte imbalances. Patients with electrical burns or major thermal burns may have peripheral neurologic injuries, which may not become evident for several days after the injury. The neurologic assessment includes use of the Glasgow Coma Scale.
Maintaining an adequate mean arterial pressure is essential to ensure adequate cerebral perfusion pressure.

Answer 34

Ineffective Cerebral Tissue Perfusion

Question 35

Ineffective peripheral tissue perfusion results from third spacing of fluid during the resuscitation phase, which restricts blood flow to extremities. As hypovolemia ensues, vasoconstriction increases, which can be potentiated by the loss of body temperature.
Specialty mattresses and beds may be helpful to prevent secondary skin breakdown and assist with positioning and pulmonary hygiene. The limbs should be elevated above the heart to decrease peripheral edema and enhance venous return. Assisted range-of-motion exercises can help decrease edema.
Monitoring the peripheral circulation is crucial in a patient with circumferential, full-thickness burns on the extremities. The resulting edema may severely compromise the venous system and then the arterial system. Neurovascular integrity of extremities with circumferential burns must be assessed every hour for the first 24 to 48 hours using the six Ps: pulselessness, pallor, pain, paresthesia, paralysis, and poikilothermy.
Irreversible nerve ischemia resulting in loss of function may begin after 12 to 24 hours.
An escharotomy may become necessary to allow the underlying tissue to expand. In deeper wounds, a fasciotomy, which involves incision into the fascia, may be necessary.

Answer 35

Ineffective Peripheral Tissue Perfusion

Question 36

Paralytic ileus is a common GI complication that can occur during resuscitation or when sepsis develops, because blood flow can decrease up to 60%. An abdominal examination should be performed every 2 hours during the initial phase and every 4 hours thereafter.
If clinical manifestations of a paralytic ileus occur, oral intake is withheld, and a nasogastric tube may be inserted and placed on low suction.
Invasive monitoring.
Hypothermia.
Laboratory assessment.

Answer 36

Ineffective Gastrointestinal Tissue Perfusion

Question 37

requires careful consideration of the potential risk factors and how the data collected will influence the course of treatment. Invasive monitoring should be considered if treatment seems ineffective or if complicating factors such as severe respiratory involvement, major life-threatening injuries, head injuries, or pneumothorax occur. Patients with preexisting medical conditions such as chronic obstructive pulmonary disease, acute heart failure, and kidney failure also may require invasive monitoring.
includes direct measurement of CVP, pulmonary artery pressure, arterial pressure, core temperature, cardiac output, SVR, and PVR.
The risks involved include the increased chance of infection, potential for pneumothorax, and difficulty with insertion if hypovolemia is present.

Answer 37

Invasive monitoring.

Question 38

Maintenance of thermoregulation is a nursing challenge. A patient with extensive burn injury is at high risk for hypothermia. Hypothermia is especially problematic during initial treatment, during hydrotherapy, during dressing changes, and immediately after surgery.
maintained between 37.6 C (99.6 F) and 38.3 C (101 F).

Answer 38

Hypothermia.

Question 39

it is done only if absolutely indicated.
Consideration should be given to the age of the patient, the size of the burn, the time since injury, and any underlying disease process.
White blood cell counts usually are monitored for elevation, a sign of sepsis.
Hemoglobin and hematocrit data can be useful in the resuscitative phase to guide fluid administration. If surgical débridement is required, monitoring blood counts in the postoperative period is important. Serum chemistry information is helpful for ongoing assessment of kidney function and electrolyte balance. The myriad tests available should be used appropriately and as indicated by individual patient needs.

Answer 39

Laboratory assessment.

Question 40

begins after resuscitation and lasts until complete wound closure is achieved. The early postresuscitation phase is a period of transition from the shock phase to the hypermetabolic phase. Major cardiopulmonary and wound changes occur that substantially alter the manner of patient care from that given during resuscitation.
Cardiopulmonary stability is optimal during this period, because wound inflammation and infection have not developed.
Hypermetabolic changes can be complicated with the onset of wound infection and sepsis. Early wound excision and skin grafting procedures, local wound care, nutrition support, and infection control characterize this phase.
nurses provide wound care, hydrotherapy, débridement, preoperative and postoperative management, and pain management.

Answer 40

Acute Care Phase

Question 41

Management of the burn wound is the top priority after the resuscitation phase. The depth of the burn wound is the principal determinant of wound management. Expedient closure of the wounds decreases the potential for many complications such as fluid and electrolyte imbalances, loss of proteins and nitrogen, and infection.
The major goal of burn wound care is wound closure.
Initial débridement is done by removal of blisters and loose skin.
The following objectives must be met for optimal wound closure: control of infection through meticulous cleansing and débridement, promotion of reepithelialization, and preparation of the wound for grafting and closure. Other goals are reduction of scarring and contracture formation and providing patient comfort with appropriate psychological support and pharmacologic intervention.

Answer 41

Impaired Tissue Integrity

Question 42

Sources of contamination include the patient’s endogenous flora found on the skin, the upper respiratory tract, and the GI tract.
Exogenous flora found in the patient care setting include bacteria carried by staff members and present in the environment.
Patient-specific factors that predispose the patient to infection include age, diabetes, steroid therapy, extreme obesity, severe malnutrition, and infections in remote sites.
A burn wound infection can delay healing and increase scarring, and invasive infection can result in death of the patient.
Other factors that affect wound healing are tissue hypoxia from low blood flow to the burn wound, presence of eschar that requires débridement, exudate on the wound that can be harmful to the granulating wound or consume oxygen in the wound, and trauma to the wound from daily dressing changes or lack of protection from the outside environment.

Answer 42

Factors Affecting Healing of the Burn Wound

Question 43

A variety of equally appropriate methods can be used to cleanse burn wounds (e.g., sterile normal saline at the bedside, tap water in a hydrotherapy room).
Wounds are gently cleaned with a gauze dressing or washcloth and patted dry before application of topical agents. Hydrotherapy facilitates the removal of debris and loose eschar.
Frequent cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection.
Wound care exposure is limited as much as feasible to prevent hypothermia and decrease exposure to bacteria.
must receive adequate premedication with analgesics, opiates, and sedatives.

Answer 43

Wound Cleansing

Question 44

Although many options for burn wound care are available, the basic principle of maintaining a moist wound environment while preventing wound infection is the standard of care. Benefits include preventing wound desiccation, optimal function of local wound growth factors and proteolytic enzymes to remove dead tissue, increased reepithelialization and collagen synthesis, and decreased wound fluid loss.
most common regimen for burn wound care involves the application of a topical antimicrobial agent, followed by a primary nonstick dressing
outer layer is applied to provide increased absorption, compression, and occlusion
method is useful for less severe wounds when the amount of drainage has decreased and wound closure has almost been achieved

Answer 44

Wound Care

Question 45

Burn injuries destroy the function of the skin’s protective mechanism, including the function of sebaceous glands. Sebaceous glands normally secrete sebum, which contains fatty acids, including oleic acid. In addition to lubricating the skin, sebum is believed to help destroy some microorganisms, such as streptococci and some strains of staphylococci.
Serum is lost from damaged capillaries, providing a rich nutrition medium for bacterial colonization. Topical antibiotic agents are used to control this colonization.
SSD is a broad-spectrum antimicrobial agent with bactericidal action against many gram-negative and gram-positive bacteria associated with burn wound infection.
SSD is indicated for use with partial-thickness and full-thickness wounds.

Answer 45

Topical Antibiotic Therapy

Question 46

Eschar is the nonviable tissue that forms after a burn injury. This tissue has no blood supply, and polymorphonuclear leukocytes, antibodies, and systemic antibodies cannot reach these areas.
Eschar provides an excellent medium for bacterial growth,Débridement facilitates wound healing by removing contaminated tissue of foreign bodies and bacteria, controlling the inflammation, and removing the devitalized tissue, preparing the wound bed for grafting or biological dressing application.
Mechanical débridement.
Enzymatic débridement.

Answer 46

Wound Débridement

Question 47

Includes rough débridement, wet-to-dry débridement, and sharp débridement with the use of scissors and forceps or curette

Answer 47

Mechanical débridement.

Question 48

débridement involves the topical application of proteolytic substances to the wound bed such as Santyl. These agents are useful in softening eschar and dissolving devitalized tissue while sparing healthy tissue. They promote the separation of eschar, which can lead to earlier wound closure.
gold standard of débridement remains surgical débridement, which is performed by a surgeon.
The goal of débridement is to remove nonviable tissue down to bleeding viable tissue with an electric dermatome or surgical knife.
Fascial excision is used when the wounds are deep and the fat does not appear viable.

Answer 48

Enzymatic débridement.

Question 49

To assist in wound closure, many temporary and permanent skin substitute dressings have gained popularity in the United States.
Temporary substitutes are designed for placement on partial-thickness or clean, excised wounds. Permanent substitutes provide a permanent skin replacement.
Skin substitutes must possess properties that mimic the native epidermis and dermis. They are made from various synthetic materials such as nylon, polyurethane, or solid silicone polymers.
Skin barrier substitutes must possess several properties to accomplish their desired effect as a temporary wound covering to protect the granulating tissue and to preserve a clean, viable wound surface for future autografting. The most important property of these materials is adherence so that the skin substitute can simulate the function of the skin.

Answer 49

Skin Substitutes

Question 50

is a skin graft harvested from a healthy, uninjured donor site on the patient with burns and then placed over the patient’s burn wound to provide permanent coverage of the wound.
provide permanent wound coverage.
Preferred sites for obtaining these grafts are the thighs, back, and abdomen; however, grafts can be harvested from almost anywhere on the body.
Autografting with the patient’s own skin from a donor site is the preferred choice for wound closure.
Previously used and healed donor sites can be used again on later return visits to the operating room.
Mesh grafts can cover more area but may not produce the cosmetic appearance desired; therefore they are usually placed on areas covered by clothing.
Grafts can be secured with sutures, fibrin glue, or staples.

Answer 50

Autograft

Question 51

The common purpose of skin substitutes is to replicate the properties of normal skin.

Answer 51

Biosynthetic Skin Substitutes

Question 52

The lack of available donor sites for major burn injury often delays wound closure. In an effort to minimize infection and to promote healing, many attempts have been made to develop skin substitutes that seal the wound in a functional and cosmetically acceptable fashion.
This therapy is being recommended as an adjunct for traditional split-thickness skin grafts, and it continues to be investigated and combined with newer dermal skin substitutes.

Answer 52

Synthetic Skin

Question 53

The basal metabolic rate of a patient with burns may be elevated 40% to 100% above the normal rate, depending on the amount of TBSA involved. The metabolic rate is influenced by the amount of protein and albumin lost through the wounds; the catabolic response associated with stress, injuries, fluid loss, fever, infection, and immobility; sex; and height and weight of the patient before the injury.
The goal in nutrition management of a patient with burns is to provide adequate calories to enhance wound healing. To achieve this goal, nutrition support and a reduction of energy demand are imperative. Every effort should be made to reduce the release of catecholamines, which increase metabolic rate. Pain, fear, anxiety, and cold stimulate release of catecholamine stores. Appropriate interventions for each of these stimuli must be performed.
Because of the increased nutrition needs of patients with large-surface-area burns, oral feedings are usually inadequate, and supplemental enteral feedings are necessary. After burn injury, intestinal mucosal damage and increased bacterial translocation occur, resulting in decreased absorption of nutrients. Therefore nutritional support should ideally be initiated within 24 hours of injury via an enteral route.
Initiating early enteral feedings has shown to alleviate malnutrition and stress reaction, strengthen immunity, and promote gastrointestinal mobility, thereby promoting wound healing.

Answer 53

Imbalanced Nutrition: Less Than Body Requirements

Question 54

As more patients with larger and deeper burns survive, the challenge to maintain their optimal mobility and cosmetic appearance has been met with increased success.
A contracture is the shortening of a scar over a joint surface and is the primary cause of functional deficits in patients with burns
Contractures develop as a result of various factors including the extent, depth, location, and configuration of the burn; the position of comfort the patient most frequently assumes; the relative underlying muscle strength; and the patient’s motivation and compliance. The affected body parts should be positioned to prevent long-term deformity. Frequent change of position also is important and may need to be performed as often as every hour. Although contracture prevention is the goal, many patients with burns will develop self-limiting contractures despite aggressive prevention measures and good care. Early identification of high-risk patients is a useful endeavor.
Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness.
Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises.
Active exercise is encouraged and is preferred, although active-assisted or gentle-passive exercises also may be an important part of the rehabilitation program. Active exercise maintains muscle mass, aids in restoring protein structures within the muscle tissue, aids in venous and lymphatic return, and reduces the risk of pulmonary embolus and deep vein thrombosis. The patient’s tolerance must be carefully evaluated.

Answer 54

Impaired Physical Mobility

Question 55

The goal of scar management is to minimize scarring, making the skin flat, elastic, and close to the original color. It is important to inform the patient that the tissue may not return to the preburn texture or appearance despite good efforts.
The highest risk for scar tissue development is associated with deep partial-thickness and full-thickness burns because of their depth and increased risk of infection.
Scar maturation occurs 6 months to 2 years from the time of the injury.
One method to reduce scar formation is timely application of uniform pressure. Custom-made elastic pressure garments are worn for 6 months to 1 year, if needed
These garments reduce scar blood flow and may provide force that helps developing collagen to organize. Although compression therapy is one of the main methods of prophylaxis and treatment of burn scars, its mechanism is not totally understood.
Additional approaches to reduce scarring are scar massage, high-SPF sun protection, silicone gel sheeting, laser therapy, and steroid treatment.

Answer 55

Scar Management