T14: Burns & Skin Infections Flashcards
burns
an injury to the tissues of the body caused by heat, chemicals, electrical current or radiation
When you break skin barrier it is a
MASSIVE RISK FOR INFECTION
Decreased circulating intravascular blood volume leads to
fluid loss can cause decrease in organ perfusion : HR increases, CO and BP decrease
why do we need fluids in burn patients
the fluid is extravascular but the blood in the vessel is THICK so we are worried about a DVT!!!
thermal burns
caused by flame, flash, scald or contact with hot objects; this would even be considered as a sunburn
chemical burns
Result of contact with acids, alkalis, and organic compounds
Alkali burns are hard to manage because they cause protein hydrolysis and liquefaction
immediate care of chemical burns
o Chemical should be quickly removed from the skin (lavage with water *think about eye wash stations)
o Clothing containing chemical should be removed
o Tissue destruction may continue up to 72 hours after chemical injury
smoke inhalation injury
injury occurs with inhaling of products of combustion during fire
clinical manifestations smoke inhalation injury
facial burns, SINGED NASAL HAIRS, swelling of oropharynx and nasopharynx, stridor, wheezing, dyspnea, hoarse voice, sooty (carbonaceous) sputum and cough
electrical burns can cause
“Iceberg effect;” muscle spasms strong enough to FRACTURE BONES
with electrical burns patients are at risk for
o Dysrhythmias or cardiac arrest –>VF, cardiac standstill (place on a monitor)
o Seizures (place on seizure precautions)
o Muscle movement is affected (heart, intercostals, diaphragm, walking)
o Severe metabolic acidosis
o Myoglobin and hemoglobin from damaged RBCs travel to kidneys
- Acute tubular necrosis (ATN)
- Eventual acute kidney injury
superficial partial thickness burn
Involves the epidermis
deep partial thickness burn
involves the dermis
full thickness burn
involves all skin elements, nerve endings, fat, muscle, bone
rule of nines
a method used in calculating body surface area affected by burns
Face, neck, chest burns risk for
respiratory obstruction
Hands, feet, joints, eyes burn risk for
self-care deficit and mobility
Ears, nose, buttocks, perineum burn risk for
infection
Circumferential burns of extremities can cause
circulation problems distal to burn
compartment syndrome check
6 Ps
6 P’s
Pain
Pulse
Pallor
Paresthesia
Paralysis
Pressure
pre hospital care for burns
- Remove person from source of burn and stop burning process
- Rescuer must be protected from becoming part of incident
- ASSESS ABCs
- Cover burns with sterile or clean clothes and remove constricting jewelry and clothing
at the hospital care for burns
o O2 100%
o IV access to non-burned skin or central line
o Fluids for hypovolemia
o Insert foley to manage fluid resuscitation of 30-50mL/hr
o NPO
o NG tube to remove gastric secretions and prevent aspiration
o TETANUS
interventions for electrical burns
- Removal of current source must be done by trained personnel with special equipment to
prevent injury to rescuer - Assess and tx pt after removal from source of current
intervention for chemical burns
o Brush solid particles off skin
o Use water lavage
o Tissue destruction may continue for up to 72 hours after
small thermal burn interventions
o Cover with clean, cool, tap water—dampened towel
large thermal burn interventions
o Circulation (check for presence of pulse), airway (patency), breathing
o Cool burns for no more than 10 minutes (in order to prevent hypothermia)
o Do not immerse in cool water or pack with ice-hypothermia
o No ice-vasoconstriction
o Remove burned clothing
o WRAP IN CLEAN, DRY SHEET OR BLANKET
§ DRY OTHERWISE WET WILL DRY AND PULL OF SKIN
how to wrap burns
o WRAP IN CLEAN, DRY SHEET OR BLANKET
- DRY OTHERWISE WET WILL DRY AND PULL OF SKIN
inhalation injury intervention
o Watch for signs of respiratory distress
o Treat quickly and efficiently
o 100% humidified oxygen via non-rebreather if CO poisoning is suspected
emergent stage begins
at time of the injury
emergent stage ends
when fluid mobilization and diuresis begin
clinical manifestations of emergent stage
- Shock from HYPOVOLEMIA
- Blisters
- Paralytic ileus
- Shivering
- Altered mental status
goal of emergent stage
maintain patent airway, administer IV fluids to prevent hypovolemic shock and preserve vital organ functioning
Normal insensible fluid loss
30-50 mL/hr
severely burned patient fluid loss
200 to 400 mL/hr
As RBCs are destroyed more K+ gets in blood so
WATCH K+ AND NA+ LEVELS
burn shock
a type of hypovolemic shock; if not corrected, can result in DEATH
IMMUME SYSTEM IS CHALLENGED WHEN BURN OCCURS because
the skin barrier is destroyed, bone marrow is depressed, circulating level of immune globulin are decreased, WBC develop defects
burns and CV system
Dysrhythmias and hypovolemic shock, increased blood viscosity (sludging)
escharotomy
§ (a scalpel or electrocautery incision through the full-thickness eschar) is frequently done after transfer to a burn center to RESTORE CIRCULATION TO COMPROMISED EXTREMITIES.
burns and respiratory system
Edema formation, mechanical airway obstruction and asphyxia, pneumonia, pulmonary edema
burns and urinary system
- ↓ Blood flow to kidneys causes renal ischemia
- Acute tubular necrosis (ATN) due to myoglobin from muscle damage ->myoglobinuria and hemoglobinuria-PINK urine that is not formed RBCs
· Would need to be on CRRT
fluid therapy
- TWO LARGE BORE IV LINES FOR >15 %
- > 30% CENTRAL LINE
- 0.9 NS
-LR and albumin
-DAILY WEIGHTS TO DETERMINE ADEQUATE FLUID REPLACEMENT
Wound care should be delayed until
patent airway, adequate circulation, and adequate fluid replacement have been achieved
Hydrotherapy (burns)
cleansing can be done on a shower cart in a shower or on a bed
· Once daily shower, dressing change in morning and evening, preemedicated before procedure
debridement
loose necrotic skin is removed
open method
burn is covered with topical antibiotic with NO dressing over wound
open method of wound care
· STERILE gauze dressing are laid over topical antibiotic
· APPLICATION OF SILVER SULFADIAZINE TO MOISTENED GAUZE
autografting
surgical removal of a thin layer of clients own skin which is then applied to the excised burn wound
Other Care measures for burns
Ears should be kept free of pressure
· No use of pillows
Hands and arms should be extended and elevated on pillows or foam wedges
Perineum must be kept as clean and dry as possible
· Indwelling catheter
· Perineal care
Routine laboratory tests
Early ROM exercises
· Early PT to prevent complications and facilitate fluid mobilization and healing
pain management drugs
analgesics, sedatives, morphine, ect
Antimicrobial drugs
silver sulfadiazine, mafenide acetate
Tetanus immunization or ImmuneGlobulin
o routinely given to all burn patients
nutrition therapy for burns
High protein, carb, fat and vitamins; lots of calories (5000+)
acute phase for burns begins with
- mobilization of extracellular fluid and subsequent diuresis weeks to months HEMODYNAMICALLY STABLE
- DIURESIS from fluid mobilization OCCURS, and patient is less edematous
- Bowel sounds return
- Healing begins as WBCs surround burn wound and phagocytosis occurs
acute phase for burns ends with
- Partial thickness wounds are healed and/or
- Full thickness burns are covered by skin grafts
- Necrotic tissue begins to slough
GI complications for burns
-Paralytic ileus: things like fluid status and stool softeners
- CURLING’S ULCER: PPI and H2 BLOCKERS, prevention is helped if patient feeding occurs as soon as possible after the burn injury
dermatome
Donor skin is taken from the patient for grafting by means of a DERMATOME, which removes a thin (14/1000 to 16/1000 inch) split-thickness layer of skin from an unburned site.
dermatome intervention
Nurse has to take care of donor and graft site MUST STAY MOIST AND STERILE
hyperbaric oxygen therapy
flood that part of body with O2 to promote healing
How to put on compression sleeve
roll down then roll up the extremity
rehabilitative stage of burns begins when
- Wounds have healed
- Patient is engaging in some level of self-care
rehab stage ends
o Rehab goes on FOREVER
-Consider emotional and psychological needs as well
parkland formula for burns
- TBSA x 4mL x wt (kg) = 24 hour volume
o Then divide in half - 1st ½ over 8 hours divided by 8
2nd ½ over 24 hours divided by 16
Staphylococcus aureus
o Impetigo, folliculitis, cellulitis, and furuncles
o MRSA-verify by culture
Group A β-hemolytic streptococci
o Impetigo, erysipelas, cellulitis, and lymphangitis
Erysipelas-red demarcated (RED HOT AND CAN BECOME SYSTEMIC) clinical manifestations
Fever, HA, INCREASED WBC, toxic
Erysipelas treatment
- Possible Bacteremia
- Antibiotics-PCN based
Cellulitis clinical manifestations
Fever, chills, malaise
Cellulitis Treatment
- Moist heat, immobilization, elevation
- IV antibiotics
-Vancomycin, linezolid-Zyvox, daptomycin-Cubicin
Impetigo intervention
o SOAP/WATER TO LOOSEN CRUSTS THEN PAT DRY THEN PUT OINTMENT mupirocin topical
medications for herpes simplex
ACYCLOVIR, valacyclovir
herpes zoster clinical manifestations
o Unilaterally clusters skin vesicles along the peripheral sensory nerves, burning and pain
herpes zoster interventions
o Isolate client, prevent rubbing and scratching, light weight clothing
o Medications-Same but sooner to prevent neuralgia
o Neuralgia-gabapentin, pregabalin
o VACCINE-ZOSTAVAX FOR >50 YO
Candida
white cheese like discharge (thrush/ yeast infection)
o MOUTH IN BETWEEN FINGERS, ALL OVER BODY, IT ITCHES LIKE CRAZY
interventions for candida
CAN GIVE ANTIHISTAMINE LIKE BENYDRYL
o Keep skin folds clean and dry, frequent mouth care
Tinea clincial manifesations
scaly surfaces, nail beds
Tinea interventions
o Keep areas dry
o Medications-topical or systemic Azoles, fluconazole, ketoconazole»Watch liver enzymes
management for skin infections
Þ Wet compresses-quality or sterile water
o Warm/tepid or cool for antinflammatory
Þ Baths
Þ Topical medications
o Gels, lotions, creams, ointments
o Occlusion with plastic wrap increases absorption and blood levels-caution
Þ Control of pruritus
o Break the itch/scratch cycle: KNUCKLE SCRATCH
o Cool environment
o Hydration, wet compresses, moisturizers
o Topical drugs
Þ Prevention of spread
o Careful hand washing and the safe disposal of soiled dressings
Þ Prevention of secondary infections-scratching
Steven Johnson Syndrome (SJS)
COMMON SEVERE DRUG REACTION/CHANGE IN MEDICATION
If untreated SJS
TEN (toxic epidermal necrolysis- tissue is actually dying)
clincial manifestations of SJS
o Fever, flulike, erythema and blisters 24-96 hours
o Eye, mucus membranes, GI tract, urogentital
o Immunosuppression and opportunistic infections
- Sepsis and PNA common
- NO CORTICOSTEROIDS
- Immuneglobulin may help
o Prevent progression to deeper tissues
interventions for SJS
o STOP SUSPECTED AGENT IMMEDIATELY
o Silver based and biologic dressings
o ICU care
- Fluid resuscitation
- Enteral or parenteral nutrition
Necrotizing Fasciitis
a severe infection caused by Group A strep bacteria inflammation of fascia producing death of the tissue
Clincial Manifestations of Necrotizing Fasciitis
o Localized, painful, edema, induration, crepitus, EXTREME PAIN
