T1 - Integument and Burns (Josh) Flashcards
— burns are the number 1 cause of burn injury to kids under 4.
Scald
What about kids make them more susceptible to scald burn injury?
thinner skin than adults
What is the temp we should keep water heaters?
120 degrees or less
***always test water with BACK of hand
Describe the patho of a burn injury.
Hemodynamics, lead to…
Increasced capillary permeability, leading to…
Plasma leaking into interstitial spaces, leading to…
Fluid loss, leading to…
Increased peripheral vascular tissue resistance, leading to…
Organ hypoperfusion, leading to…
Burn Shock
What happens about 24 hours out from a burn injury?
Capillary membrane integrity is restored, leading to DIURESIS
Patho of Burns:
Within first few hours, we have —- due to leaky capillaries creating edema and increased vascular tissue resistance.
After 24 hours, we have — due to repair of capillaries.
Organ Hypoperfusion
Diuresis
What are the different degrees of burn injuries?
Superficial (1st Degree)
Partial Thickness (Superficial Dermal) (2nd Degree) Partial Thickness (Deep Dermal) (2nd Degree)
Full Thickness (3rd Degree)
Deep Full Thickness
Degrees of Burn Injury:
Which ones have pain?
First and Second Degree
***Third usually doesn’t due to nerve damage
***Deep Full Thickness never has pain
Degrees of Burn Injury:
Describe the appearance of a 1st Degree Burn.
Epidermis
Severe Erythema
Blanches
Red, pink, dry
NO BLISTER
Degrees of Burn Injury:
How long does a 1st Degree Burn last?
Pain for 48-72 hrs
Desquamation in 3-7 days
Heals in 2-7 days
Degrees of Burn Injury:
Describe the appearance of the two types of 2nd Degree burns.
Superficial Dermal
- Large, thick walled BLISTER
- Cherry red, edema
- Mottled red base
- Broken epidermis
- Wet, shiny, weeping
- Blistered
Deep Dermal
- NO BLISTER
- Red, patchy white areas that BLANCH with pressure
- Moderate edema
Degrees of Burn Injury:
Describe the time frame of a 2nd Degree Superficial Dermal burn.
Superficial healing in 7-21 days while deeper healing takes 21-28 days
Mid-dermal healing takes 4-6 wks
MINIMAL SCARRING
Degrees of Burn Injury:
Describe the time frame of a 2nd Degree Deep Dermal burn.
2-6 wks to heal
Spontaneous healing or will require surgical excision and skin grafting
Dermal Necrosis = wound turns from white to yellow
Degrees of Burn Injury:
What is the appearance of a Full Thickness 3rd Degree Burn?
Pale, white, charred
Deep red, black, brown
Dry leathery surface
Severe edema
Fat exposed
Tissue disrupted
No blisters
Degrees of Burn Injury:
What is appearance of a Deep Full Thickness Burn?
Black
NO EDEMA
Degrees of Burn Injury:
Why would a 3rd Degree burn victim pee out blood?
hemolysis of blood leads to blood passed into urine
Degrees of Burn Injury:
Is a 3rd Degree burn capable of self re-epithelialization?
no
skin grafts required
Rule of 9s:
Give percentages to each part that is rated in the Rule of 9s.
Head and Neck = 9 percent
Anterior Trunk = 18 percent
Posterior Trunk = 18 percent
Arms = 9 percent (each arm)
Legs = 18 percent (each leg)
Perineum = 1 percent
Rule of 9s:
What would a burn on upper half of anterior trunk be?
9 percent
***remember full anterior trunk is 18 percent
Do peds patients use Rule of 9s?
No,
they use something like the Lunds-Browder which adjusts surface area for age
Circumferential Burns:
What is the biggest concern with burn that covers the entire circumference of an extremity?
circulation and respiration (if it’s the chest and back)
why? because fluid shifts create problems, especially if skin cannot stretch to account for it
Circumferential Burns:
What do you do with an extremity that has a burn that covers entire circumference?
elevate above heart
check distal pulses q hr
***may also cut into skin to relieve interior pressure
Circumferential Burns:
Why do a lengthwise incision with these types of burns?
Escharotomy-skin cannot expand
Lengthwise incision relieves constriction
NOTES:
- little to no bleeding
- can be done at bedside
- treatment of choice
Signs and Symptoms of an Inhalation Injury
SOB, dyspnea
Hoarsesness
Stridor
Flaring
Tachypnea
Burns to face, neck, mouth
Sooty Sputum
Singed Facial Hair
Swelling of face, neck, trachea
Explain why an Inhalation Injury leads to hypoxemia.
Carbon Monoxide binds to Hg and decreases O2 delivery to tissues
With an inhalation injury, what is protocol to determine O2 level?
ABG and Carboxyhemoglobin level
***pulse ox will not be accurate
What can smoke inhalation lead to?
ARDS
Bronchospasm
Atelectasis
Edema
Infection
***Due to the fact that smoke decreases surfactant production
Carbon Monoxide Poisoning:
What is Normal?
Mild?
Moderate?
Severe?
Fatal?
Normal = less than 2 percent
Mild = 11-20 percent
Moderate = 21-40 percent
Severe = 41-60 percent
Fatal (death) = 61-80 percent
Carbon Monoxide Poisoning:
Signs and Symptoms of Mild (11-20 percent) CO poisoning?
HA
Decreased cerebral function
Decreased visual acuity
Slight breathlessness
Carbon Monoxide Poisoning:
Signs and Symptoms of Moderate (21-40 percent) CO poisoning?
HA
Tinnitus
Nausea
Drowsiness
Vertigo
Confusion
Stupor
Irritability
Hypotension
Pale to reddish purple skin
Carbon Monoxide Poisoning:
Signs and Symptoms of Severe (41-60 percent) CO poisoning?
coma
convulsions
cardiac instability
Treatment for Inhalation Injury
100 percent FiO2 ASAP
EARLY INTUBATION (to prevent swelling from keeping tube out)
Rest
Maintain airway
PEEP
Phases of Burn Care:
What are the 3 phases?
Resuscitation Phase
Acute Care Phase
Rehabilitation Phase
Phases of Burn Care:
Which phase is the emergent phase and how long does it last?
Resuscitation Phase
- it is when fluid shifts and lasts until plasma volume is restored
Phases of Burn Care:
What happens during the Acute Care Phase?
Spontaneous Diuresis
Return of Capillary integrity
Mobilization of ECF
Wound healing, closure, and prevention of complications
Phases of Burn Care:
Describe the Rehabilitation Phase.
Begins at admission
Long term
Mobility and Function
Psychological Recovery
Phases of Burn Care:
What are the goals of the Acute Phase?
Prevent Infection (death in this stage is typically from infection)
Wound Care (skin grafting)
Nutrition
Phases of Burn Care:
What are the goals of the Resuscitation Phase?
minimize the effects of fluid shifts and maintain organ perfusion
***first 24-36 hrs they’ll have elevated HCT and Hgb so use LR, then, use Albumin (colloids)
Resuscitation Phase:
During the initial 24 hrs…
What happens to HCT and Hgb?
What happens to Sodium?
What happens to Potassium
HCT and Hgb are elevated due to loss of fluid volume as fluid shifts into interstitial space
Sodium decreases (hyponatremia) due to third spacing
Potassium (hypoerkalemia) increased due to cell destruction
Resuscitation Phase:
After the initial 24 hours (48-72 hrs after injury…
What happens to HCT and Hgb?
What happens to Sodium?
What happens to Postassium?
HCT and Hgb decrease due to fluid shift from interstitial space back into vascular space
Sodium remains decreased due to renal and wound loss
Potassium remains decreased due to renal loss and movement back into cells
Resuscitation Phase:
What happens to WBC, Glucose, ABGs, Protein and Albumin, and Carboxyhemoglobin during this phase?
WBC - initial increase then decrease with left shift
Glucose - elevated due to stress response
ABGs - slight hypoxemia and metabolic acidosis
Albumin (Protein) - low due to fluid loss
Carboxyhemoglobin - elevated
Resuscitation Phase:
What is the end result of an elevated Carboxyhemoglobin level during this phase?
Due to inhalation injury
- carboxyhemoglobin competes with O2 for Hgb binding, which leads to hypoxia
Resuscitation Phase:
What would a physical assessment of Circulatory System reveal?
Hypovolemia
HR increased
CO decreased
Decreased CVP
Decreased UOP
Resuscitation Phase:
What would a physical assessment of the Pulmonary System reveal?
***inhalation injury
Airway edema
Pulmonary capillary leak
Chest burns and restriction
CO poisoning
Resuscitation Phase:
What would a physical assessment of the GI System reveal?
SNS (Fight or Flight) Response
- slowing of gastric motility
- ileus
- curling’s ulcer (give H2 blockers to treat)
Metabolic
- stress response activated
- Hypermetabolic condition
Circumferential Injury:
What would the physical assessment be in the injured limb?
Pulsesless
Paresthesia
Numbness
Why would a burn victim be cold (hypothermic)?
heat loss through open wound
***burn units are warmer than rest of hospital
Resuscitation Phase:
What are Airway Mgmnt goals during this phase?
Intubation
Mechanical Vent
100% FiO2 if inhalation injury or head, neck, upper thorax burn
Resuscitation Phase:
What are the goals to keep client Hemodynamically Stable during this phase?
Keep UOP 0.5-1 mL/kg/hr
Keep SBP greater than 90
ECG to monitor for changes associated with electrolyte imbalance
Fluid resuscitation
Resuscitation Phase:
Management Goals
Emergent fluid resuscitation
Start large bore IV away from burn area (central line prefered)
Keep UOP 0.5-1 mL/kg/hr
Expect to gain 15% base weight in emergent phase
1st 24-36 hrs = isotonic solutions…then switch to colloids (Plasma, Albumin, Hespan)
Resuscitation Phase:
What is Parkland Formula and how do you use it?
formula to determine the amount of fluids to give during resuscitation phase
4 mL LR x %TBSA x weight in Kg
***%TBSA determined with rule of 9s
- Give half this amount in first 8 hrs
- Give 25% over next 8 hrs
- Give 25% over next 8 hrs
Resuscitatino Phase:
70 kg Client has burn over entire anterior trunk. Use Parkland Formula to determine how much fluid to give
Rule of 9s = anterior trunk = 18 percent
Parkland Formula = 4mL x 18 x 70 = 5040 mL
Give 2520 in first 8 hrs
Give 1260 in second 8 hrs
Give 1260 in last 8 hrs
Resuscitation Phase:
How would we manage pain?
IV Narcotic
NO IM or SQ meds due to fluid shifts
NO PO due to GI Distress
Resuscitation Phase:
Which injection should we make sure they have?
Tetanus injection
***would be the only thing we give IM during this time
What is the most common cause of death after a burn injury?
Infection
Resuscitation Phase:
What can we do do to manage the GI problems associated with burns?
NG Tube if paralytic ileus
H2 Blockers, Antacids (maintain gastric pH greater than 5)
NPO (TPN - hyperalimentation)
Resuscitation Phase:
What would we set the NG Tube to at the beginning?
Suction first to keep stomach decompressed
Once we know that there is motility occurring, then we’ll give them nutrition through the tube
Resuscitation Phase:
During first 48-72 hrs, how often are we monitoring UOP?
q 1 hr
Resuscitation Phase:
What are signs of renal failure?
Hemoglobinuria
Myoglobinuria (dark urine from muscle/tissue damage)
Hypoperfusion
Hypovolemia
Burn Shock:
What is it and when would we most likely see it?
Hypovolemic shock associated with major shift of lfuids out of blood vessels
usually seen during Resuscitation Phase if we do not adequately maintain fluid status
Burn Shock:
What are the hemodynamics associated with Burn Shock?
Decreased CO
Decreased BP
Tachycardia
Increased SVR
Increased PVR
When is the Acute Phase?
What is sign of Acute Phase?
When does it end?
36-72 hrs after burn
Onset of Diuresis (due to capillary repair)
Ends with Wound Closure
Acute Phase:
What are the management goals during this phase?
Control Infection
Wound Closure
Wound Cleansing and Debridement
Promote Re-epithelialization
Provide Adequate Nutrition
Pain Management:
What can we do to manage pain?
IV Opioids (Morphine and Fentanyl)
Benzos
**NO IM or SubQ meds
Acute Phase:
What are we monitoring with WBCs?
elevation and sign of sepsis
***WBCs may drop more than 5000 after 48 hrs of burn injury
Acute Phase:
What is Pan-Culture?
when they have an increased temp, they will culture for everything (pan-culture)
Acute Phase:
What is done prophylactically for burns with greater than 10% TBSA?
Tetanus
Signs of Sepsis
Decreased BP
Tachycardia
Shivering (Fever)
Types of Debridement:
What are the different types?
Which one can a trained nurse do?
Which one will be avoided if nerves are exposed?
Types:
- Mechanical
- Enzymatic
- Surgical
Nurse can do mechanical
Enzymatic will be avoided if nerves are exposed
Topical Ointments:
What are pros and cons of Silver Sulfadiazine (Silvadene)?
Pros:
- maintains joint mobility
- effective against gram - bacteria, gram + bacteria, and yeast
- not painful
Cons:
- may cause neutropenia
- no sulfa allergies
- does not penetrate eschar
- contraindicated in newborn and pregnancy
Topical Ointments:
What are pros and cons of Mafenide Acetate (Sulfamylon)?
Pros:
- active againts gram pos and gram neg bacteria
- penetrates eschar
- DOC for electrical burns
Cons:
- painful to apply and remove
- have to apply twice a day
- inhibits wound healing
Wound Care:
What does the Open Method entail?
No dressing
Topical agents
Wound Care:
What does the Semi-Open Method entail?
Topical agents
Thin layer of gauze
Xeroform gauze (nonadherent dressing)
Wound Care:
What does the Closed Method entail?
Topical agents
Nonadherent dressing (Xeroform)
Woven gauze dressing
Silver impregnated dressings
Wound Care:
What are Silver Dressings?
How do they work?
99.1 percent pure metallic silver, 0.9 percent silver oxide
Interfere with bacterial enzyme systems
***moisture is required through intermittent application of sterile water
Skin Grafts:
What are the temporary grafts?
Homografts (Allografts)
- human cadaver
- rejected in 2 wks
Heterografts (Xenografts)
- Pigs
- rejected in 5-7 days
Acute Phase:
What is preferred route of nutrition?
oral or enteral (TPN if gut not working)
Acute Phase:
What are daily protein and calorie requirements?
Protein = 2-4 x’s normal amount
Calories = 8000 cal a day
Acute Phase:
If they can eat, what type of meals and how often?
Several small meals daily with high protein and high calorie
Rehab Phase:
How should we position client?
Fowlers without a pillow
Elavate and Extend the extremity (to prevent contractures)
Anti-deformity positions (with splints that are removed q 2 hrs)
Rehab Phase:
What can be worn to prevent contractures?
JOBST Garment
**wear for about a year
