Multisystem (Burns & shock) Flashcards
Protocols to follow like open heart surgery; order to doing stuff
Wax and wayne - may have to backwards
Resuscitative Phase:
Acute Care Phase
The rehabilitative phase of care of the patient with burns
Nursing management - phases of care
starts at the initial hemodynamic response to injury and lasts until capillary integrity is restored and fluid replacement has occurred. The goal is to maintain vital organ function and perfusion. Emergent interventions for inhalation injury, airway management, and hypovolemia are concurrently addressed.
Begins prehospital
Ends when wound closure is achieved
Resuscitative Phase:
begins after resuscitation (the onset of diuresis) and lasts until complete wound closure is achieved.
Start having third spacing
Fluid moving from extravascular and intravascular - wounds heal and not as edematous and start to heal
Acute Care Phase
starts from the admission of the patient and may last years, depending on future surgical procedures, therapy needs, contracture prevention, and psychological or emotional needs of the patient.
Long-term: years
Therapy to gain full range of motion
Skin grafts
After know will live
The rehabilitative phase of care of the patient with burns
Very beginning
In hospital setting
What kill first
Oxygenation Alterations
Fluid Resuscitation
Risk for Infection
Hyperkalemia:
Hypokalemia
Hyponatremia
Ineffective Tissue Perfusion
Invasive monitoring
Hypothermia
Laboratory assessment:
Resuscitative phase
Airway and Breathing
Have to have both to have adequate oxygenation and ventilation
What are we assessing? - Oxygenation Alterations
Lot airway - inhalation injury; burns inside mouth - swelling associated with that - mouth, tongue, pharynx - swell to point to completely occlude airway
Related to: - Oxygenation Alterations
Laryngeal and facial swelling
See face first
Specks black in oral cavity from soot of smoke
Breathing: carbon monoxide levels elevated because in environment on levels of high carbon monoxide - occupying spot on RBC
Edema
Burns
Severely chapped lips
Talking - listen to way speech is: hoarse; normal for you; normal voice - lower at glottis level with swelling - decompensate quickly
Assess depth and rate respirations - try compensate for low O2 levels - not getting enough in so increase RR
Assess: - Oxygenation Alterations
100% O2 on them no matter what
High carbon monoxide SpO2 inaccurate
If have burns on thorax (ant and post chest) - affects ability to move chest in and out - escharotomy - sharp scalpel and then spreads
Treatment: - Oxygenation Alterations
Deficient fluid volume
Fluid shifts - intracellular to extracelluar
Circulation: - Fluid Resuscitation
Hypovolemic shock - hypovolemia relative because fluid not where supposed to be
Burn shock - Fluid Resuscitation
hyperkalemia, hypokalemia, hyponatremia
Leaked out
Electrolytes in fluid that is being leaked out
Electrolyte imbalance: - Fluid Resuscitation
Very high risk
What is the most common source of infection?
What are some infection control measures?
Risk for Infection
Dirty environment when have injuries to dermis - try clean wounds but already in there on surface
Common source: Bacteria - from dermis, poor hand hygiene, stuff on the skin
What is the most common source of infection?
Wash hands
What are some infection control measures?
Causes:
release of potassium from damaged cells
metabolic acidosis
impaired kidney function caused by hemoglobinuria, myoglobinuria, or decreased renal perfusion.
Hyperkalemia:
Causes:
massive loss of fluids and electrolytes through the burn wounds
hemodilution from fluid resuscitation.
Inadequate replacement
diuresis
diarrhea
vomiting, nasogastric drainage,
long hydrotherapy sessions
Shift of potassium from the intravascular space to the cell after the acidosis has been corrected.
Hypokalemia
Causes:
the loss of sodium through the burn wound
the shift of fluid into the interstitial space
vomiting, nasogastric drainage
diarrhea
the use of hypotonic salt solutions during the early phase of resuscitation.
Hyponatremia
Ensure end organ perfusion adequate
About blood and components of blood not in vascular space - in tissue - not circulating
Kidney
Cerebral
Gastrointestinal
Peripheral
Ineffective Tissue Perfusion
Related to
Hgb - Hemoglobinurea - extra Hgb circulating - big molecules of kidneys not like filtering it out
Hypoperfusion cause kidney issue
Hypovolemia
Assess:
Muscle breakdown and myoglobin in urine - urine looks brown raspberry iced tea color
Kidney
Related to
End organ perfusion
Not have blood in vascular space - not circulate to head - hypoperfuse brain
Associated with head injury - in environment long enough and face planted - head injury
Carbon monoxide poisoining and Hypoxemia and Electrolyte balance
Assess:
Baseline neuro assessment - LOC - before and throughout stay
Know carbon monoxide levels elevated - as come down neuro levels should improve
Cerebral
Related to
Paralytic ileus is a common GI complication that can be related to hypokalemia, the sympathetic response to severe trauma, or decreased tissue perfusion related to hypovolemia
Ileum not have peristalsis so have bowel obstructions - because of K - need K at this level to make it work
Assess:
bowel sounds in all 4 quads, high risk for GI bleeding - high risk for having more liquid stool; peristalsis above and below blockage; not necessary whole ileum and what get past ileum is water so have watery stools - one first see with eyes that is a problem
Circumferential abdominal burns:
Burns in thorax and have swelling - see swelling - swells outwards and inwards - smushing guts: intraabdominal compartment syndrome
assess for abdominal compartment syndrome. Is caused by intra-abdominal hypertension (IAH) - pressure in abdominal cavity. IAH is an IAP greater than or equal to 12 mm Hg (normal 5 to 7 mm Hg).
First see swelling - pushing on all organs under it
Important structure - aorta then get CV sys - decrease CO, preload
Assess for
Gastrointestinal
Quantify with special catheter with extra ports - push saline in bladder and put up to transducer and up to abdominal cavity
If it >12 focus assessment - decrease output, more incidence of ileus and other organ dysfunc
Pressing on aorta - issues with venous return - BP down - not have preload - no BP - compound with lack circulating volume - crump fast
Need be symptomatic first - now radar and assessing for other probs - pressure 20 not package deal of escharotomy
Increased pressure see - Decreased cardiac output, decreased tidal volume, increased peak pulmonary pressure, decreased urine output, and hypoxia.
Measured with a transurethral bladder pressure catheter
Surgical decompression (escharotomy - burn and cut through hard eschar tissue) of the abdomen may be required for IAP > 20 to 25 mm Hg accompanied by a taut, tense abdomen and signs of organ dysfunction - HAVE TO HAVE SX - actively treat need sx
Not have obvious burns - fasciotomy to give room to swell
Assess for
Burns all around - squeezing effect
Compensatory mechanisms - not lot fluid circulating - now constrict to get BP with what do have
Combining burn with vasoconstriction - issues with perfusion to extremities
Related to vasoconstriction secondary to hypovolemia
Assess CMS on all extremities.
Circumferential burns: Assess for pulselessness, pallor, pain, paresthesia, paralysis, and poikilothermy (defn: the inability to maintain a constant core temperature independent of ambient temperature)
Doc CMS to distal extremity
Pulses start weaker and sides getting cooler - emergency - cont swell and get worse
An escharotomy may be needed to allow the underlying tissue to expand - straight line and swelling spreads it
In deeper wounds, a fasciotomy (incision into the fascia) may be necessary - swelling deeper - all through levels dermis to muscle and cut between to open fascia so muscle can swell somewhere
Peripheral
Need to do this when caring for them
Invasive monitoring includes direct measurement of CVP, pulmonary artery pressure, arterial pressure, core temperature, cardiac output, SVR, and PVR.
Arterial line is considered if serial and frequent arterial blood gas values are required for respiratory management or for hemodynamic instability requiring the titration of vasoactive medications.
Lot ABGs
Central venous catheters: to deliver the massive volume of fluids required.
Pulmonary artery catheters are placed only when necessary for optimal care.
May or may not get this
Go straight to invasive montioring - need to know CVP and need bigger access - large bore IV
Invasive monitoring
Look at CVP - quantify preload so ensure vena cava not getting smushed; vascular volume
No way to prevent it from going intravascular to extravascular but we can monitor it
Monitor fluid resuscitation
Take a lot volume - Judge if adequately/enough volume
Look at all hemodynamics
Invasive monitoring includes direct measurement of CVP, pulmonary artery pressure, arterial pressure, core temperature, cardiac output, SVR, and PVR.
Package deal with getting this
Getting lot fluid very quickly and need large vein to accept it at that speed
Using Rapid infusers used/pressure bag
Central venous catheters: to deliver the massive volume of fluids required.
What causes hypothermia in this population?
Probs managing temp
Not have intact dermis and what is there is damaged and ineffective - heat is kept in body here - hard regulate temp
Burn units very hot - ambient air warmer - not cool for staff (gowned up for infection control)
Dressings off - issues with regulation
The patient’s core temperature should be maintained between 37.6° C (99.6° F) and 38.3° C (101° F).
Heat is lost through open burn wounds by means of evaporation and radiation
Hypothermia can occur during initial treatment, hydrotherapy, dressing changes, and immediately after surgery.
Hypothermia
Need serial labs
Laboratory values, when paired with the physical assessment, provided a complete picture of the patient’s end organ perfusion, electrolyte assessment, and complete blood count.
Watch labs because shift of fluids - electrolytes follow fluid; electrolytes within norm limits (cardiac and neuro issues); gut needs adequate K for adequate peristalsis; always electrolyte probs with phase - package deal with phase and fluid location
White blood cell counts usually are monitored for elevation, a sign of sepsis. However, it is not unusual for the white blood cell count to fall to less than 5000/mm3 within 48 hours after injury.
High risk for infection
Not all septic infections get but high risk
Hemoglobin and hematocrit data can be useful in the resuscitative phase to guide fluid administration.
Serum chemistry to assess kidney function and electrolyte balance.
End organ perfusion - Cr and BUN
Which electrolytes do we need to focus on?
Hyperkalemia
Hypokalemia
Na
What causes the electrolyte imbalance?
Hyperkalemia - Release K from damaged cells - damaged and releasing contents into vascular space; get from acidotic state; Kidney func - Taking kidneys with myoglobinurea and lower perfusion - messes with K
Hypokalemia - massive amount fluids giving to maintain adequate amount of perfusion
Na - lost through burn wound; shift from intravascular to extravascula
Laboratory assessment:
electrical shock - through the muscle to break it down
Burn highest risk for having myoglobinurea -
First degree - redness to the face and neck
Second degree - patchy white areas that blanch with pressure
Third degree - pale with charred areas
An 80 Kg patient presents to the emergency department with redness to the face and neck, the upper chest and back are pale with charred areas, and the left upper (front & back) and right lower (top only) arm are red with patchy white areas that blanch with pressure. IV fluids are running through 2 large bore IVs. NG tube is to low intermittent suction. Blood is sent to the lab. The patient is agitated but answers questions appropriately. Their voice is hoarse. When speaking to the patient, the nurse notices that the patient has singed nose hairs and black, carbon deposits on their lips.
Which type of burns does this patient have?
Yes
voice is hoarse
singed nose hairs and black, carbon deposits on their lips
Does this patient have any signs or symptoms of an inhalation injury?
Face - 4.5
Thorax - 18%
Left upper (front and back) - 4.5
Right lower (top only) - 2.25
29.25%
What is the % of the surface area burned?
Stable - nothing with ABCs concerning
100% O2 and start fluid resuscitation - A before C
Assess ABCs <20sec
Lot issues with airway so anticipate and consider intubation before diff intubation because massive amount edema in oral airway and glottis
What intervention should the nurse anticipate next?
Not care about Sat prob - reading carbon monoxide and O2 on RBC - finger probe - getting 100% oxygen
Have both airway and breathing
Breathing - shallow respirations with poor chest wall excursion
Airway - expiratory wheezing; anything from oral cavity to mainstem bronchus
MAP soft
HR elevated as comp mechanism
Issues with oxygenation and ventilation - not in good place
The patient is put on 100% high-flow oxygen via a non-rebreather mask and transported to the burn unit. 4 hours later, the nurse assesses the patient again. Neuro: The patient is lethargic but is oriented to person, place, and time. CV: S1,S2, no advantageous heart tones. Right arm: doppled pulse, warm, reddened skin tone, 3/10 pain, no numbness/decreased sensation reported. left arm: doppled pulse, pale, cool 9/10 pain, + tingling, decreased sensation. lungs are course throughout with expiratory wheezing, rapid, shallow respirations with poor chest wall excursion. Urine output is 30 ml/hr and is a dark red color. Vital signs: BP 101/48 (65), HR 128, RR 28, SaO2 91% ABG: pH 7.32 PaCO2 50 HCO3 20 PaO2 76
Is this assessment concerning? Why/Why not?
Raspberry tea colored urine
Muscle break down
What does the urine color indicate?
Both burns were second degree
Left arm was circumferential - smushing in on vascular bed but also nerves smushing - so have sensory probs
Great enough pressure - affecting nerves - not that forgiving; first pins and needles, then no feeling, then painful; perfusion back - painful for awhile
Why is the left arm more painful than the right?
Priority: airway: losing his airway - if we can do tube - tube him; if not trach him - going 4 hours - deteriorating quickly; prepare for intubation - kit and bed ready and pt ready
2. Not able to expand in burns: crusty and constricted - hard sided luggage - not expand to get extra stuff in; burn circumferential on chest - can go in - affects ability to breath; do escharotomy bedside; scalpel - getting through crust and swelling exands out to wound - makes chest func again - more wall excursion: classic when burns on front and back
Intubate for airway; prepare for escharotomy for breathing
3. Circulation: arm not getting perfusion (pale, cool skin) - must perfuse it; volume resucictation - ensure doing this adequately; fasciotomy
Must do all 3 together
If crust start with escharotomy (third degree); fasciotomy (second degree burns - cut up so expand)
What should the nurse prepare for next?
Extravascular fluid going back into intravascular fluid - more stable - not requiring as much fluid resuscitation
The acute care phase begins after resuscitation (the onset of diuresis) and lasts until complete wound closure is achieved.
Impaired Tissue Integrity
Skin Substitutes mimic the native epidermis and dermis
Temporary substitutes:
Permanent substitutes
Definitive Burn Wound Closure
Acute care phase
Still issue with this
Still have wounds healing
Prevent anything that stops the process of healing
What factors affect the healing of the burn wound?
Wound Cleansing
Hydrotherapy facilitates the removal of debris and loose eschar
Wound Care:
Topical Antibiotic Therapy
Wound Debridement:
Mechanical Debridement:
Enzymatic debridement: Topical proteolytic is applied to the wound.
Surgical debridement.
Impaired Tissue Integrity
Not get an infection - natural flora on skin
Inconteninet - E coli from stool
Diabetic - higher risk for infection
CHF and bad CO need good CO to perfuse areas to heal
tissue hypoxia
More aggressive when debriding eschar tissue - once gone - open wound again - higher risk for infection
Daily dressing change - peeling off of burnt skin or scab
What factors affect the healing of the burn wound?
Gently clean with gauze dressing, pat dry, and apply topical ointment
Cleaning wounds
Abx ointment and nice dressings
Wound care detailed
Cleaning burns - cleaning and putting abx ointment on
Wound Cleansing
Measures to reduce pain (analgesics, opiates, sedatives) and hypothermia are required
Gentler way of debriding
Taking off dead tissue instead scrubbing
Imp to be gone so heal
Painful - premedicated and medication tweaked during procedure
Hydrotherapy facilitates the removal of debris and loose eschar
Not want wounds to dry - want moist environment - bacteria loves it
Maintaining a moist wound environment while preventing wound infection is the standard of care.
Apply a topical antimicrobial agent, followed by a primary nonstick dressing. An outer layer is applied to provide increased absorption, compression, and occlusion
Using silver-impregnated dressings can reduce dressing change frequency - bacteria not grow on silve
Wound Care:
Used to control bacterial colonization
Protocol and physician based
Abx base
Most silver based creams - silver impregnated 4x4s because bacteria not grow on silver
The most used topical antibiotics are SSD (Silvadene cream), mafenide acetate cream (Sulfamylon), bacitracin ointment, and silver impregnated into the primary dressing
Topical Antibiotic Therapy
Removal of nonviable tissue (eschar) that has no blood supply, and polymorphonuclear leukocytes, antibodies, and systemic antibodies cannot reach these areas.
Ambiguous - what debride - color with blue dye so know gotten deep enough and whole area
Ensure get whole surface necessary
Wound Debridement:
nonviable tissue is manually removed using scissors and forceps.
Mechanical Debridement:
Softens the eschar and dissolves devitalized tissue while sparing healthy tissue.
Promote the separation of eschar, which can lead to earlier wound closure.
Eschar hard as rock - put enzyme in it to digest it away
Enzymatic debridement: Topical proteolytic is applied to the wound.
A surgical procedure to remove nonviable tissue down to bleeding viable tissue with an electric dermatome or surgical knife.
In OR
Sometimes in room
Go lot deeper
Very painful
Need general anesthesia
Surgical debridement.
Dermis may or may not come back - not regenerate if full-thickness - Get into grafts
Nice pink and scarred then products
Long process - with grafts never baseline - always distortment - sometimes lot scar
Skin Substitutes mimic the native epidermis and dermis
Designed for placement on partial-thickness or clean, excised wounds.
Cover open wound to help prevent infection
Most long-term
Temporary substitutes:
provide a permanent skin replacement
Permanent substitutes
Long-term; deeper 2nd degree and 3rd degree
Excision and grafting: 3rd- burns and some deep dermal partial thickness burns
Grafts
Synthetic Skin
Definitive Burn Wound Closure
Autograft
Biosynthetic Skin Substitutes
Grafts
is a skin graft harvested from a healthy, uninjured donor site on the patient
Take skin off non burned and put on burned area - looks like webbing - not solid - tack on with sutures/staples on edges
Best - less chance rejection
Autograft
Cadaver skin
Homografts (allografts): Homograft skin can be obtained from living donors or deceased donors (cadaver skin)
Heterografts (xenografts): a graft transferred between two different species to provide temporary wound coverage. The most common and widely accepted xenograft is pigskin (porcine skin)
Biosynthetic Skin Substitutes
Diff types synthetic skin (skin substitutes)
Integra functions as a temporary skin replacement that attaches to the open wound until the skin tissue grows enough to be replaced by skin grafts. It is a two-layer sheet with the inner layer created from tendon material from cows and a substance called glycosaminoglycan made from shark cartilage. The outer layer is silicon-based with a clear and natural appearance to view the skin tissue reconstruction
Synthetic Skin
The rehabilitative phase of care of the patient with burns starts from the admission of the patient and may last years, depending on future surgical procedures, therapy needs, contracture prevention, and psychological or emotional needs of the patient.
Much later
Planning rehab early; can predict needs early based on surface area and types of wounds; actual rehab phase starts later
Moved from wounds, preventing infections to mental health issues and mobility issues
Impaired Physical Mobility
Scar Management
Rehabilitation phase
Contractures that develop after a burn injury
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.
Splints used to prevent contractures must be checked daily for proper fit and effectiveness.
Impaired Physical Mobility
Scars - Contract and shrink
On face - Can have issues with dry eye; issues with eating
Multiple surgeries where debulk scar tissue
The goal of scar management is to minimize scarring, making the skin flat, elastic, and close to the original color
Areas of the skin that required skin grafting also have a visible scar.
Scar formation can be reduced with compression garments.
Scar massage stretches the scar and provides moisture
Surgical excision may be recommended
Scar Management
- debride, abx ointment, infection control big
Acute phase
fluid management; ABCs, prevent big comps
Resucitative phase -
Shock is a life-threatening manifestation of circulatory failure that leads to cellular and tissue hypoxia resulting in cellular death and dysfunction of vital organs.
Shock is characterized by decreased oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization leading to cellular and tissue hypoxia
Effects of shock are reversible in the early stages and a delay in diagnosis and/or timely initiation of treatment can lead to irreversible changes including multiorgan failure (MOF) and death
There are mainly 3 broad categories of shock
Shock
Life-threatening prob
Simplest terms - something affecting tissues from getting oxygenated
Shock is a life-threatening manifestation of circulatory failure that leads to cellular and tissue hypoxia resulting in cellular death and dysfunction of vital organs.
Septic, anaphylactic, or neurogenic
Hypovolemic:
Characterized by decreased intravascular volume and increased systemic venous assistance a.nd end‐organ hypoperfusion
Cardiogenic:
Characterized by severe impairment of myocardial performance that results in diminished cardiac output, poor end‐organ hypoperfusion, and hypoxia
There are mainly 3 broad categories of shock
Low volume
Just preload problem
Definition: Inadequate fluid volume in the intravascular space.
Causes: Hemorrhage from any source, intravascular volume to the interstitial space, severe vomiting or diarrhea, diuresis.
How does the decreased preload cause a decreased cardiac output?
Name compensatory mechanisms seen in hypovolemic shock
Assessment
Management
Hemodynamics of hypovolemic shock
Hypovolemic shock
