Exam #2: Burns Flashcards
1
Q
Types of Burn Injury
A
- Thermal burns
- Chemical burns
- Smoke inhalation injury
- Electrical burns
- Cold thermal injury
2
Q
Thermal Burns
A
- Caused by flame, flash, scald, or contact with hot objects
- Most common type of burn injury
3
Q
Thermal Burns: Severity of injury depends on
A
- Temperature of burning agent
- Duration of contact time
4
Q
Chemical Burns
A
- Result of contact with acids, alkalis, and organic compounds
- Tissue destruction may continue up to 72 hours after chemical injury
5
Q
Chemical Burns: Alkaline burns
A
- Alkali burns are hard to manage because they cause protein hydrolysis and liquefaction
- Damage continues after alkali is neutralized
*read notes
6
Q
Chemical burns result in injuries to
A
- Skin
- Eyes
- Respiratory system
- Liver and kidney
7
Q
Chemical Burns: What do you do initially?
A
- Chemical should be quickly removed from the skin
- Clothing containing chemical should be removed
8
Q
Smoke Inhalation Injury
A
- From inhalation of hot air or noxious chemicals
- Cause damage to respiratory tract
- Major predictor of mortality in burn victims
- Need to be treated quickly
9
Q
What are the three types of smoke inhalation injuries?
A
- Metabolic asphyxiation (i.e carbon monoxide poisoning)
- Upper airway injury
- Lower airway injury
10
Q
Smoke Inhalation Injuries: Metabolic asphyxiation
A
- Carbon monoxide (CO) poisoning
- CO is produced by incomplete combustion of burning materials
- Inhaled CO displaces oxygen leading to hypoxia, carboxyhemoglobinemia and death.
11
Q
Carbon Monoxide Poisoning hypoxia and death occurs when
A
- CO levels are 20% or greater
- May occur in the absence of burn injury to skin
12
Q
How do you treat carbon monoxide poisoning?
A
100% humidified oxygen
13
Q
Smoke Inhalation Injury: Upper airway injury
A
- Injury to mouth, oropharynx, and/or larynx
- Thermally produced: Hot air, steam, or smoke
- Swelling may be massive and onset rapid
14
Q
Smoke Inhalation Injuries: Upper airway injuries -> Swelling
A
- Eschar and edema may compromise breathing
- Swelling from scald burns can be lethal
15
Q
What are reliable clues to upper airway injury caused by smoke inhalation?
A
- Presence of facial burns
- Singed nasal hair
- Hoarseness, painful swallowing
- Darkened oral and nasal membranes
- Carbonaceous sputum
- History of being burned in enclosed space
- Clothing burns around neck and chest
16
Q
Smoke Inhalation Injury: Lower Airway Injury
A
- Injury to trachea, bronchioles, and alveoli
- Injury is related to length of exposure to smoke or toxic fumes
- Pulmonary edema may not appear until 12 to 48 hours after burn (Manifests as acute respiratory distress syndrome (ARDS))
17
Q
Electrical Burns
A
- Result from coagulation necrosis caused by intense heat generated from an electric current
- May result from direct damage to nerves and vessels, causing tissue anoxia and death
18
Q
Electrical Burns: Severity of Injury depends on
A
- Amount of voltage
- Tissue resistance
- Current pathways
- Surface area
- Duration of flow
19
Q
Electrical Burns: Current/Electric Sparks
A
- Current that passes through vital organs will produce more life-threatening sequelae than current that passes through other tissue
- Electrical sparks may ignite patient’s clothing, causing a combination of thermal flash injury
20
Q
Electrical Burns: Severity of injury can be difficult to assess because
A
-most damage occurs beneath the skin “iceberg effect”
21
Q
Electrical Burns: Affect on bones
A
Electrical current may cause muscle spasms strong enough to fracture bones
*Read notes
22
Q
Electrical Burns can place a patent at risk for
A
- Dysrhythmias
- Cardiac arrest
- Severe metabolic acidosis
- Myoglobinuria
*Read note
23
Q
Electrical Burns: Effect on kidneys
A
Myoglobin and hemoglobin from damaged RBC’s can travel to kidneys leading to acute tubular necrosis and eventual acute kidney injury.
*Read notes
24
Q
Severity of Burn injury is determined by
A
- Depth of burn
- Extent of burn in percent of TBSA
- Location of burn
- Patient risk factors
25
Classification of Burn Injury: Depth of Burns
- Burns have been defined by degrees (first, second, third and fourth)
- ABA advocates categorizing burn according to depth of skin destruction (partial-thickness burn versus full-thickness burn)
26
Depth of Burn: Superficial partial thickness burn (1st degree)
Involves epidermis
27
Depth of Burn: Deep partial-thickness burn (2nd degree)
Involves dermis
28
Depth of Burn: Full-thickness burn (3rd and 4th degree)
Involves all skin elements, nerve endings, fat, muscle and bone
29
Extent of Burn: Two commonly used guides for the totals body surface area:
1. Lund-Browder chart: considered more accurate (because the patients age, in proportion to relative body-area size is taken into account)
2. Rule of Nines: used for initial assessment
30
Classification of Burn: Location of Burn
- Face, neck, chest -> respiratory obstruction
- Hands, feet, joints and eyes -> self-care
- Ears, nose, buttocks, perineum -> infection
*Read notes
31
Rule of Nines: Head/Face
4. 5% for the front
| 4. 5% for the back of the head
32
Rule of Nines: Anterior/Posterior Chest
18%
33
Rule of Nines: Groin
1%
34
Rule of Nines: Arms
4.5% front and back of arm
| I.e the whole front and back of arm is burned = 9%
35
Rule of Nines: Legs
9% for front of leg and 9% for back of leg
| I.e the entire leg is burned = 18%
36
Location of Burn: Circumferential burns of the extremities can cause
- Circulation problems distal to the burn.
| - Patients may develop compartment syndrome.
37
Burn Injury: Patient risk factors
- Preexisting heart, lung, and kidney diseases contribute to poorer prognosis
- Diabetes mellitus and peripheral vascular disease contribute to poor healing and gangrene
- Physical weakness renders patient less able to recover (i.e alcoholism, drug abuse, malnutrition)
- Concurrent fractures, head injuries, or other trauma.
38
Phases of Burn Management
1. Emergent (resuscitative)
2. Acute (wound healing)
3. Rehabilitative (restorative)
39
Emergent Phase
- Time required to resolve immediate problems resulting from injury (restore normal fluid balance)
- Up to 72 hours
40
What are the primary concerns during the emergent phase?
1. Hypovolemic shock
| 2. Edema
41
Emergent Phase Pathophysiology: Fluid and electrolyte shifts are caused by
* Greatest threat is hypovolemic shock
| - A massive shift of fluids out of the blood vessels as a result of increased capillary permeability.
42
Conditions Leading to Burn Shock (Slide 39)
- At the time of major burn injury, capillary permeability is increased.
- All fluid components of the blood begin to leak into the interstitium, causing edema and a decreased blood volume.
- The red blood cells and white blood cells do not leak.
- Hematocrit increases, and the blood becomes more viscous.
- The combination of decreased blood volume and increased viscosity produces increased peripheral resistance.
- Burn shock, a type of hypovolemic shock, rapidly ensues, and if it is not corrected, death can result.
43
Emergent Phase Pathophysiology: What happens as fluid and electrolytes shift?
- Colloidal osmotic pressure decreases (because plasma proteins move into the interstitial spaces and surrounding tissue)
- More fluid shifting out of vascular space into interstitial spaces (d/t the decrease is colloid osmotic pressure)
44
Emergent Phase Pathophysiology: Insensible fluid loss in severely burned patient
200-400 mL/hour (cover them up/the wound to reduce insensible loss)
(Normal is usually 30-50 mL/hr)
45
Emergent Phase Pathophysiology: Net result of fluid shift is
Intravascular volume depletion:
- Edema
- Decreased BP
- Increased pulse
46
Emergent Phase Pathophysiology: How is the circulatory system effected by the fluid and electrolyte shifts caused by burns?
- RBCs are hemolyzed by a circulating factor released at time of burn
- Thrombosis
- Elevated hematocrit
47
Emergent Phase Pathophysiology: K+ and Na+ shifts
- K+ shift develops first because injured cells and hemolyzed RBCs release K+ into extracellular spaces
- Na+ rapidly moves to interstitial spaces and remains until edema formation ends
48
Emergent Phase Pathophysiology: Inflammation and Healing
-Neutrophils and monocytes accumulate at site of injury
-Fibroblasts and collagen fibrils begin wound repair within first 6 to 12 hours after injury
(Huge risk for infection).
49
Emergent Phase: Immunologic Changes
Immune system is challenged when burn injury occurs:
- Skin barrier is destroyed
- Bone marrow is depressed
- Circulating levels of immune globulins are decreased
- WBCs develop defects
50
Emergent Phase: Clinical Manifestations
- Shock from hypovolemia
- Blisters
- Paralytic ileus (gut not perfused)
- Shivering (trying to regulate body temperature)
- Altered mental status (d/t lack of oxygen to brain and severe pain)
*Read notes
51
Emergent Phase Complications: Cardiovascular System
- Dysrhythmias and hypovolemic shock (hyperkalemia or electric passed through)
- Impaired circulation to extremities
- Tissue ischemia
- Paresthesias (circumferential burn)
- Necrosis
- Impaired microcirculation and ↑ viscosity → sludging
- Venous thromboembolism (VTE)
*read notes on slide 51
52
Eschatology
(a scalpel or electrocautery incision through the full-thickness eschar) is frequently done after transfer to a burn center to restore circulation to compromised extremities.
53
Emergent Phase Complications: Respiratory System
- Upper airway burns:
- edema formation
- mechanical airway obstruction and asphyxia
- Lower airway injury
- Pneumonia
- Pulmonary edema
*Read notes
54
Emergent Phase Complications: Urinary System
- ↓ Blood flow to kidneys causes renal ischemia
| - Acute tubular necrosis (ATN)
55
Emergent Phase Nursing/Interprofessional Management: Airway Management
- Early endotracheal intubation
- Escharotomies of the chest wall
- Fiberoptic bronchoscopy (flush bronchus with normal saline and remove dead tissue through ET tube if burn is inside the bronchus; other reasons too)
- Humidified air and 100% oxygen
*Read notes
56
Emergent Phase Nursing/Interprofessional Management: Fluid Therapy includes
- Two large-bore IV lines for >15% TBSA
- Type of fluid replacement based on size/depth of burn, age, and individual considerations
- Parkland (Baxter) formula for fluid replacement
*Read notes
57
Emergent Phase Nursing/Interprofessional Management: Wound Care should be delayed until
Should be delayed until a patent airway, adequate circulation, and adequate fluid replacement have been achieved
58
Parkland Baxter Formula **
4 mL of LR x kg x total body surface area (TBSA)
(24 hours to administer this fluid, however, half the fluid should be administered within the first 8 hours of the injury; the next 8 hours you give half of what is left)
59
Partial Thickness Wounds: Describe
are pink to cherry red and wet and shiny with serous exudate. These wounds may or may not have intact blisters and are very painful when touched.
60
Full Thickness Wounds: Describe
Full-thickness wounds have no blisters and will have only minor, localized sensation because nerve endings have been destroyed.
61
Emergent Phase Nursing/Interprofessional Management: Wound care consists of
1. Cleansing: Can be done on a shower cart, in a shower, or on a bed
2. Debridement: May need to be done in the OR; Loose necrotic skin is removed
3. Shower: once daily; dressing change in morning and evening
62
Burns Wound Care: Infection
- Infection is most serious threat to further tissue injury
-Source of infection is patient’s own flora
- Preventing cross-contamination is a priority
63
Wound Care Methods: Open Method
- Burn is covered with topical antibiotic with no dressing over wound
- Usually limited to the care of facial burns
64
Wound Care Methods: Multiple dressing changes or closed method
- Sterile gauze dressings are laid over topical antibiotic
| - Dressings may be changed from every 12 to 24 hours to once every 14 days
65
Wound Care: When open burn wounds are expected, the staff should wear
- Disposable hats
- Masks
- Gowns
- Gloves
*Read notes
66
Wound Care: Allograft or homografts skin
- Usually from cadavers
| - Typically used with newer biosynthetic options
67
Other burn care measures: Facial care
Performed by open method
68
Other burn care measures: Eye care for corneal burns
- Antibiotic ointment is used
- Periorbital edema may frighten patient
*Read notes
69
Other burn care measures: Ears
- Should be kept free of pressure
| - No use of pillows
70
Other care measures: Perineum
- Must be kept as clean and dry as possible
- Indwelling catheter
- Perineal care
71
Emergent Phase: Drug Therapy
1. Analgesics and sedatives
2. Tetanus immunization (routinely given to all burn patients)
3. Antimicrobial agents
4. VTE prophylaxis
*Given IV!
72
Emergent Phase - Other care measures: Hands and arms
Should be extended and elevated on pillows or foam wedges
*Read notes
73
Emergent Phase Drug Therapy: Analgesics and sedatives include
- Morphine
- Hydromorphone (Dilaudid)
- Haloperidol (Haldol)
- Lorazepam (Ativan)
- Midazolam
74
Emergent Phase Drug Therapy: Antimicrobial agents include
- Topical agents:
- Silver sulfadiazine
- Mafenide acetate
- Systemic agents are not usually used in controlling burn flora:
- Initiated when diagnosis of invasive burn wound sepsis is made
*Read notes
75
Emergent Phase: VTE Prophylaxis includes
- Low-molecular-weight heparin or low-dose unfractionated heparin is started
- Those with high bleeding risk, VTE prophylaxis with sequential compression devices, or compression stockings recommended
76
Emergent Phase Other Care Measures include
- Routine lab tests
- Early ROM exercises (during ADLs and dressing changes)
*Read notes
77
Emergent Phase: Nutritional Therapy
-Fluid replacement takes priority over nutritional needs
-Early and aggressive nutritional support within hours of burn injury is important
~Caloric needs: 5,000 calories
-Early, continuous enteral feeding promotes optimal conditions for wound healing
-Supplemental vitamins and iron may be given
78
Benefits of early and aggressive nutritional support within hours of burn injury
- Decreases complications and mortality
- Optimizes burn wound healing
- Minimizes negative effects
*Read notes
79
Emergent Phase Nutritional Therapy: Hypermetabolic state
- Resting metabolic expenditure may be increased by 50% to 100% above normal
- Core temperature is elevated
- Caloric needs are about 5000 kcal/day
80
Best way to increase nutrition in burn patients
Enteral feeding
81
Acute Phase
Begins with mobilization of extracellular fluid and subsequent diuresis
82
Acute Phase concludes when
- Partial thickness wounds are healed and/or
| - Full thickness burns are covered by skin grafts
83
Acute Phase Pathophysiology
- Diuresis from fluid mobilization occurs, and patient is less edematous
- Bowel sounds return
- Healing begins as WBCs surround burn wound and phagocytosis occurs
- Necrotic tissue begins to slough
- Granulation tissue forms
- Partial-thickness burn wounds heal from edges and from dermal bed
- Full-thickness burns must have eschar removed and skin grafts applied
84
Acute Phase Clinical Manifestations:
1. Partial-thickness wounds form eschar. Once eschar is removed, reepithelialization begins
2. Full-thickness wounds require debridement
85
Acute Phase Lab Values: Sodium
1. Hyponatremia can develop from:
- Excessive GI suction
- Diarrhea
2. Water intoxication can occur (dilutional hyponatremia):
- To avoid this condition, give juices, nutritional supplements
86
Acute Phase Lab Values: Hypernatremia may develop the following
- Successful fluid replacement
- Improper tube feedings
- Inappropriate fluid administration
87
Acute Phase Lab Values: Treating hypernatremia
- Restrict Sodium in IVs
- Oral feedings
- Figure out why it happened and treat it.
88
Acute Phase Lab Values: Hyperkalemia may occur if the patient has
- Renal failure
- Adrenocortical insufficiency
- Massive deep muscle injury
(Large potassium is released from damaged cells)
89
Acute Phase Lab Values: Hypokalemia occurs with
- Vomiting, diarrhea
- Prolonged GI suction
- Lengthy IV therapy without potassium
90
Acute Phase Complications include
1. Infection
91
Acute Phase Complications : Infection
- Localized inflammation, induration, and suppuration
| - Partial-thickness burns can change to full-thickness wounds in the presence of infection
92
Acute Phase Complications - Infection: Watch for signs and symptoms
- Hypothermia or hyperthermia
- Increased heart and respiratory rate
- Decreased BP
- Decreased urine output
*Read notes
93
Acute Phase Complications: Cardiovascular and respiratory systems
- Same complications can be present in emergent phase and may continue into acute phase
- In addition, new problems might arise, requiring timely intervention
94
Acute Phase Complications: Neurological System
- No physical symptoms unless severe hypoxia from respiratory injuries or complications from electrical injuries occur
- Disorientation
- Combative
- Hallucinations
- Delirium
- Transient state
- Variety of causes have been considered
95
Acute Phase Complications: Musculoskeletal system
- Decreased ROM
| - Contractures
96
Acute Phase Complications: GI
- Paralytic ileus
- Diarrhea
- Constipation
- Curlings ulcer (stress ulcer)
*Read notes
97
Acute Phase Complications: Endocrine System
↑ Blood glucose levels
↑ Insulin production
Hyperglycemia
*Read notes
98
Acute Phase Nursing/Interprofessional Management
- Wound care
- Excision and grafting
- Pain management
- Physical and occupational therapy
- Nutritional therapy
99
Acute Phase: Wound Care includes
- Daily observation
- Assessment
- Cleansing w/ soap and water
- Debridement (enzymatic debridement)
- Dressing reapplication (cover with Antimicrobial creams)
*Read notes
100
Enzymatic debridement
Speeds up removal of dead tissue from healthy wound bed
101
Acute Phase Wound Care: Appropriate coverage of graft
- Gauze next to graft followed by middle and outer dressings (don’t want pressure on grafts*)
- Unmeshed sheet grafts used for facial grafts.
- Grafts are left open
- Complication: Blebs (air/fluid pocket)
*Read notes
102
Acute Phase Nursing/Interprofessional Management: Excision and grafting
- Eschar is removed down to subcutaneous tissue or fascia
- Graft is placed on clean, viable tissue
- Wound is covered with autograft
- Donor skin is taken with a dermatome
- Choice of dressings varies
*Read notes
103
Acute Phase Nursing/Interprofessional Management: Grafts are attached with
- Fibrin sealant
- Sutures or staples
- Negative pressure wound therapy
*Read notes
104
Excision and grafting: With early excision,
Function is restored and scar tissue is minimized
105
Donor Site Care
- The goals of donor site care are to promote rapid, moist wound healing, decrease pain at the site, and prevent infection.
- Choices of dressings vary among burn centers and include transparent dressings (e.g., Opsite), xenograft, silver sulfadiazine, silver-impregnated dressings, calcium alginate, and hydrophilic foam dressings.
- Nursing care of the donor site is specific to the dressing selected. Several of the newer dressing materials offer decreased healing time, which allows earlier reharvesting of skin at the same site.
- The average healing time for a donor site is 10 to 14 days.
*Not sure if need to know
106
Acute Phase Excision and Grafting: Cultured Epithelial Autographs
- Grown from biopsies obtained from the patient’s own skin
- Used in patients with a large body surface burn area or those with limited skin for harvesting
*Read notes
107
Acute Phase Excision and grafting: Artificial Skin
- Life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable
- Consists of both dermal and epidermal elements
*Read notes
108
Acute Phase Nursing/Interprofessional Management: Pain Management
1. Continuous background pain:
- IV infusion of an opioid
- Or slow-release, twice-a-day oral opioid
2. Treatment-induced pain:
- Analgesic and an anxiolytic
*Read notes
109
Acute Phase Pain Management: Nonpharmacolgic Strategies
```
Relaxation breathing
Visualization, guided imagery
Hypnosis
Biofeedback
Music therapy
```
110
Acute Phase Management: Physical and Occupational Therapy
-Good time for exercise is during wound cleaning
-Passive and active ROM
-Splints should be custom-fitted
(To reduce risk for contractures and maintain function)
*Read notes
111
Acute Phase Nutritional Therapy
- Meeting daily caloric requirements is crucial
- Caloric needs should be calculated by dietitian
- High-protein, high-carbohydrate foods
- Monitor laboratory values
112
Rehabilitation Phase begins when
- Wounds have healed
| - Patient is engaging in some level of self-care
113
Rehabilitation Phase Pathophysiological Changes
- Burn wound heals either by spontaneous reepithelialization or by skin grafting
- Layers of keratinocytes begin to rebuild the tissue structure
- Collagen fibers add strength to weakened areas
- Skin never completely retains its original color
- Discoloration of scar fades with time
- Scar contour elevates and enlarges
- Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch
*Read notes!
114
Rehabilitation Phase Pathophysiological Changes: Healing Times
- In 4-6 weeks area becomes raised and hyperemic
- Mature healing is reached about 12 months
*Read notes
115
Rehabilitation Phase Complications: Skin and joint contractures
- Most common complications during rehab phase.
- Positioning, splinting, and exercise should be used to minimize contracture.
*Read notes
116
Rehabilitation Phase Nursing/Interprofessional Management
-Encourage both patient and caregiver to participate in care
(I.e Skills for dressing changes and wound care)
-Use water-based creams
-Reconstructive surgery is frequently required after a major burns
-The role of exercise cannot be overemphasized
-Constant encouragement and reassurance
*Read notes
117
Emotional Needs of the Patients and Caregivers
- Many emotional and psychologic needs
- Assess circumstances of burn injury
- Burn survivors often experience anxiety, guilt, and depression
- New fears arise during recovery
- Self-esteem may be adversely affected
- Address spiritual and cultural needs
- Issue of sexuality must be met with honesty
- Family and patient support groups
*Read notes!
