Exam 3 - Burns Flashcards
Classification of Burns
Thermal - Fire/scald
Chemical
Electrical
Radiation
Rule of 9’s for Sizing burns
Head & Neck = 9 Arm = 9 ea. Leg = 18 ea. Trunk (Anterior) = 18 Trunk (Posterior = 18 Perineum = 1
Superficial Partial thickness (first degree)
Epidermis
- Red
- No Blisters
- Very painful
- Similar to sunburn
Moderate Partial thickness (second degree)
Epidermis and upper third of dermis
-Blisters
Full thickness (third degree)
All skin layers, including subcutaneous tissue
-Not painful because nerves damaged
Shock Phase of Burn Injury
- Shock: hypovolemic, emergent resuscitation
- Rapid fluid shift from the vascular compartments into the interstitial spaces
- Fluids, electrolytes and protein lost; oliguria, HYPERKALEMIA, hyponatremia, hypoproteinemia, and nitrogen losses occur
- Decreased tissue perfusion results in anaerobic metabolism = METABOLIC ACIDOSIS
- Priorities for care: tx inhalation injuries, airway management, fluid resuscitation, maintain tissue perfusion and thermoregulation
Acute (Diuretic) Phase
Follows shock stage and lasts through complete wound closure. Characterized by return of vascular integrity, fluids and electrolyte shifts, anemia, malnutrition, potential for infection and sepsis.
- Fluid shifts from interstitial space back to vascular space; hemodilution and diuresis may occur as renal flow improves
- Sodium & potassium are lost w/diuresis, protein lost via catabolism: HYPONATREMIA, HYPOKALEMIA
- Rehabilitation
- Wound healing
Rehabilitation
recuperation and healing, physical and emotional may last several years. restoration of function to the greatest extent possible, support of nutrition.
-Priorities of care: physical remobilization, continued wound care, reconstructive surgery, resocialization
Wound healing
Inflammatory phase: injury to 3-4days post injury
Proliferative: 4-20 days post injury
Maturation: 20 days to 1yr or more post injury
Chemical burn Assessment
Burning, redness, swelling, pain, resp distress if inhaled,
-Inhalation: Hoarsness, cough, singed nasal/facial hair, dark carbonaceous sputum, burning in throat, rapid/shallow respirations, low saO2
Carbon monoxide poisoning Assessment
HA, nausea, dizziness, confusion, dysrhythmias, CHERRY RED COLORING to buccal membranes and skin
Need 100% O2
Electrical burn Assessment
Charred skin, arrhythmias, entrance/exit wound, other injuries (falls, breaks), MYOGLOBINURIA
Myoglobinuria
dark ink urine
Nursing DX for burns
Fluid Volume deficit
Impaired Gas Exchange
Burn outcomes
Adequate Airway
F&E balance
Parkland Formula
Determines fluid need based on % BSA burned
4mL of LR X kg X %BSA burned
- 1st 8hr: 1/2 of total amount
- 2nd 8hr: 1/4 of total amount
- 3rd 8hr: 1/4 of total amount
Burn interventions
-Fluid resuscitation (parkland formula)
LR 1st, then colloid after first 24hr
-Maintain UO at 30-50mL/hr (for adults)
-Maintain SBP >90-100
Renal intervention for burns
Foley to monitor I/O
Monitor for myoglobinuria
GI interventions for burns
-Place NG (unless facial fx then OG), bc paralytic ileum common
-H2 blockers
-Nutrition initiated after fluids replaced
HIGH CALORIE, HIGH PROTEIN
Pain management interventions for burns
IV MEDS ONLY (GI, IM not absorbed)
Extremity Management
- Circumferential burns- monitor pulses, venous return, numbness and pain
- Escharotomy may be needed
Wound care interventions for burns
- Cleansing (Hubbard tank)
- Debridement: manual, enzymatic, surgical
- Topical antimicrobial agents, control bacterial proliferation and promote tissue granulation
Silvadene
Use with caution with renal/hepatic impairment
PAINLESS
Now use aqua gel
Sulfamylon
Most effective, penetrates eschar
May cause metabolic acidosis
PAINFUL
Silver Nitrate
Wet dressing 2-3x/ day
Stains black
May lower Na and Chloride
Open wound care
antimicrobial over wound
Closed wound care
antimicrobial coved with gauze, held in place with net dressing
Wound closure and coverage
Donor site care- moist dressings
Elevate extremity with graft, maintain immobility, monitor drainage, compression garment (Jobst suit) to decrease hypertropic scarring
