Integumentary System Part 2 Flashcards
Acute Phase= time of diuresis to wound healing
Fluids- fluids requirements decrease. Central line is best. Monitor I&O. Correct hyponatremia and hyperkalemia. Monitor all labs (CBC, CHEM panel, UA & urine color, ABGs).
Pain Management- Should have continual maintenance dose on board (MS Contin, Dilaudid, or PCA). Anxiety meds (ativan, versed) Additional pain med for physical therapy &/or dressing changes (sublimaze good choice)
Acute Phase Wound Care
Wound Care- scrupulous dsg changes start with daily washing/debridement of burn sites to remove dead necrotic tissue (eschar). Monitor for blebs that can interfere with grafts interfacing with underlying tissue. Enzymatic debriders (collogenase) speeds up removal of dead tissue. Choice of dressing/ graft depends on severity of the burn.
Grafts- mesh grafts cover a greater area but sheet-like (unmeshed) grafts result in less scarring.
Permanent auto graft is obtained from a donor site from the patient’s own body by means of a dermatome.
Cultured Epithelial Autografts (CEA) can be grown in a lab from cells taken from the patient but can take 15-25 days to grow.
Temporary grafts (allograft or homograft from skin of another individual/same species) or Xenograft (pig skin) can be used to protect underlying tissue from exposure, fluid loss, infection.
Acute Phase Wound Care Drugs
Silver Sulfadiazine (Silvadene) is most common unless there is an allergy to silver or sulfur. Check for leukopenia <3,000. Get back to 4-5,000.
Petroleum based bacitracin is clear, painless and good for face and graft sites.
Bactroban is effective against MRSA.
Transparent dsg (Opsite, Tegaderm)
Acute Phase Management
Surgical debridement (escharotomy is a surgical removal of eschar). It is used especially for circumferential burns of the chest/limbs. It releases skin to expand (lungs) or limbs to move (especially around joints to prevent contractures).
Fasciotomy is performed to prevent swelling skin from acting like a tourniquet with resultant compartment syndrome (neurovascular compromise with tissue death)
Nutrition- due to the body’s inflammatory response, the body is propelled into a hypermetabolic response that produces a catabolic state (accelerated protein catabolism, increased caloric expenditure and O2 consumption and CO2 production and activation of the endocrine stress response).
Energy requirements increase by 50% in order for proper wound and tissue repair to occur.
Acute Phase Management cont.d
Nutrition cont’d -Research recommendation: Feed the gut within 72 hours post burn with oral or enteral feedings. Nutritionist is a must and the goal is CHO 55-60%, Fat and proteins 20-25%, vitamins and minerals. Enteral feedings are best absorbed in the duodenum or jejunum. Supplemental parental fluids may be necessary.
Mobility- ROM is started from day one. Physical therapy (PT) is best while in the shower or tub for ease of movement while the skin is wet and stretchable or after dressing change. Pre procedure pain management is essential for optimum results
Burns: Complications
CV - dysrhythmias, especially with electrical/lightening burns, hypovolemic shock/ cardiogenic shock can lead to MODS, impaired circulation due circumferential burns & edema
Respiratory- upper airway obstruction due to edema and/or lower airway interstitial edema which prevents diffusion of O2 from alveoli into the circulation (potential ARDS).
Urinary- Acute tubular necrosis (ATN) due to myoglobin (muscle breakdown) and hemoglobin (RBC breakdown)
GI- paralytic ileus and stress ulcer (Curling’s ulcer) is common. Hypermetabolic /catabolic state.
Rehabilitation Phase
Rehabilitation Phase begins when the patient’s burn wounds have healed and the patient is able to resume a level of self care activity.
Months after burn injury
Goal: to assist the patient in resuming a functional role in society and to accomplish functional and cosmetic reconstructive surgery.
Most common complications during this phase:
Contractures & hypertrophic scarring
Nursing Care for Burns
Emollient water-based cream penetrates the dermis and should be applied on healed areas to keep supple.
Apply Benadryl for itching
Use of pressure garments to minimize/prevent scar proliferation.
Protection of the site from sunlight and injury since sensations are diminished.
Heat-Related Emergencies
Heat Exhaustion is a clinical syndrome characterized by fatigue, light headedness, N & V, diarrhea, and feelings of impending doom after prolonged exposure to heat over hours or days.
S & S - elevated body temperature (99.6 - 104° F) & hypotension (related to dehydration), tachypnea, tachycardia, dilated pupils, mild confusion, ashen color and profuse diaphoresis.
Nursing Care -remove person to a cool dry place, remove constrictive clothing. Monitor ABC’s and attempt oral fluid and electrolyte replacement (avoid salt tabs- nausea). IV 0.9%NS. Cool compresses.
Heat-Related Emergencies cont.d
Heatstroke- is a medical emergency and is due to failure of the hypothalamus to deal with heat stress.
S & S - hot dry skin and ashen, altered mental status (ranging from confusion to coma), hypotension, tachycardia, weakness, temperature > 104 degrees F as sweat glands stop functioning. Can lead to circulatory collapse.
Nursing Care- monitor ABC’s, 100% O2 if needed. Initiate rapid cooling measures (remove clothing, cooling sheet, ice bath/compresses, cooled IV fluids (↓ temp to 102°F or less). ECG, Foley and check urine for myoglobinuria (rhabdomyolysis) -urine will be tea colored. Prevent shivering(raises core temp)- Thorazine IV. Monitor for potential DIC (check PT)
Prevention- proper hydration during hot weather and physical exercise, teach S&S of heat stress.
