Nursing Management of Burns Flashcards
Resuscitative Phase
- Starts: initial hemodynamic response to injury
- Ends: capillary integrity is restored & repletion of plasma vol by fluid replacement occurs
- Primary Focus: maintain vital organ function & perfusion; prevent secondary injury, restore preload
Acute Care Phase
- Starts: onset of diuresis of fluid mobilized from interstitial space
-
Ends: closure of burn wound
> sometimes out of hosp already - Primary Focus: wound healing, wound closure, prevent infection
Rehabilitative Phase
- Starts from admission of pt and may last yrs, depending on future surgical procedures, therapy needs, contracture prevention, & psychological or emotional needs of pt
- Primary Focus: adequate wound healing, prevent scarring & contractures, psychosocial supprt
Burn Nursing Management - Airway
causes
assessment
-
Causes of ineffective airway
> obstruction
> edema
> heated air
> burns -
Assessment Findings
> incrd RR & HR
> incrd work of breathing
> use of accessory muscles
> stridor
> wheezing
> hoarseness
> crackles
> swelling
> sounds like snoring if soft palate burned
> singed nose hairs
When does edema develop?
First 24hrs
should assess for intubation w/in 1st hr
Burn Nursing Management - Airway
treatment
- 100% O2 non-rebreather
- early intubation
- secure airway
- most care done by provider
- avoid invasive procedures
> trach
Burn Nursing Management - Breathing
causes
-
Causes
> carbon monoxide; impairs gas exchange
> chemical -
What do we assess for
> chest rise & fall
> ABGs; retaining PaCO2 (incrd lvls)
> if PAP incrs = breahting problem
Burn Nursing Management - Breathing
treatment
-
1st 100% oxygen
> even if pulse ox above 92 -
Intubation
> even if airway is intact -
Escharotomy
> so chest wall is no longer fixed
Burn Nursing Management - Circulation
cause of deficient fluid vol
-
Loss of fluid from the vascular compartment from incrd capillary permeability into area of injury resulting in hypovolemia
> fluid, protein, electrolyte shift (hyperK, hypoK, hypoNa), and insensible water loss
Burn Nursing Management - Circulation
treatment
- 1st type of fluid: crystalloid fluid - Lactated Ringers
- 2nd type of fluid: colloid - albumin
Burn Nursing Management - Circulation: Fluid Resuscitation
goal
assessment
-
Goal
> maintain end-organ perfusion
> maintain preload -
Assessment
> urine output; adequate kidney function, will have more I & normalish O
> HR
> BP
> lungs; assess for fluid vol overload
Burn Nursing Management - Circulation: Ineffective Kidney Perfusion
r/t
assess
-
Related To
> preload
> hemoglobinuria
> myoglobinuria
> hypoperfusion
> hypovolemia -
Assess
> urine color & trend
> output amnt
> specific gravity
> urine glucose
> urine sodium
> creatinine & BUN - Mannitol
Burn Nursing Management - Circulation: Ineffective Cerebral Perfusion
r/t
assess
-
Related To
> neurological status
> head injury
> hypoperfusion r/t hypovolemia
> hypoxemia r/t inadequate ventilation
> carbon monoxide poisoning
> electrolyte imbalances
> anoxic brain injury -
Assess
> neuro status, should continue to get better
> GCS
> agitation, restless, anxious
> maintain adequate mean arterial pressure
Burn Nursing Management - Circulation: Ineffective Gastrointestinal Perfusion
r/t
assess
-
Related To
> paralytic ileus r/t hypokalemia, tthe sympathetic response to severe trauma, or dcrd tissue perfusion r/t hypovolemia
> GI bleed; high hr, low bp -
Assess
> urine output
> bowel sounds
> bowel movements
> epigastric pain
> upper GI bleed = black, tarry stools
Burn Nursing Management - Circulation: Gastrointestinal Circumferential Abdominal Burns
-
Abdominal Compartment Syndrome
> caused by intra-abdominal hypertension (IAH)
> IAH is an intra-abdominal pressure greater than 12mmHg
> normal: 5-7 mmHg -
Assessment
> measured by extra port on foley
> intermittent
Gastrointestinal Circumferential Abdominal Burns Sign/Symptoms
- Incrd ICP, dcrd CPP
- Incrd lung dysfunction
- Rising IAP pushes diaphragm further into chest
- Incrd bowel edema & ischemia
-
Incrd CVP, incrd wedge pressure
> falsely elevated - Further dcr in CO
- Worsening vena caval compression
- Dcrd perfusion, oliguria, difficulty mobilizing fluids
- Incrd acidosis
How is abdominal hypertension treated/managed?
Escharotomy
if doesn’t work, abdominal surgery
When is abdominal hypertension treated?
when symptomatic
Burn Nursing Management - Circulation: Ineffective Peripheral Perfusion
assess
interventions
-
Assess
> unburned areas
> mucus membranes
> pulses -
Nursing Interventions
> no bending
> special mattress
> elevate extremities
> passive ROM
> turns, cough, deep breath
Burn Nursing Management - Circulation: Ineffective Peripheral Perfusion
6 Ps
- Pain
- Pallor
- Pulselessness
- Parasthesia
- Paralysis
-
Poikilothermia
these are also s/s tht indicate the limb has dcrd perfusion
What causes hypothermia in this population?
- Loss of dermis
- Evaporation
Electrolytes to Focus on
- Hypokalemia
- Hyperkalemia
- Hyponatremia
What causes electrolyte imbalances
Damage to tissue, loss of permeability
What is the most common source of infection?
Burn site; open wound
cross-contamination
A patient whose arm came in contact with a car battery?
electrical burn
A pt with redness & blistering on their legs after applying fertilizer to their lawn
chemical burn
A pt post cardiac cath and had a reddened area in the middle of their back
radiation burn
A pt with blistering to the fingers after a firework exploded in their hand
thermal burn
