Tissue Integrity/Burns lecture Flashcards
Burn prevention tips
- Working smoke and carbon monoxide detectors
- Create emergency escape plans
- Never leave cooking food or open flames unattended
- Install childproof devices
- Never leave young children unattended in kitchen/bathroom
- Check electrical cords for damage
- Keep fire extingushers and practice Stop, drop, and roll
- Set home water heater to 120 degrees
- Wear protective clothing, use suncreen, avoid tanning beds
- Do not smoke or have flame in room with oxygen in use
Name the types of burns
Thermal
Electrical
Chemical
Radiation
- Burn caused by fire, steam, scald, hot objects or liquids
- Erythema, edema, blisters, and pain
Thermal
- Burns caused by contact with lightning or electrical energy source
- Can affect multiple organs, cause neuro problems, or cause sudden cardiac arrest
Electrical
- Burns caused by contact with industrial/household chemicals
- i.e Acids, alkalis, organic
- PPE is needed to avoid exposure to chemicals
- Chemical needs to be removed with continuous irrigation with water
Chemical
- Burns caused by sunning, tanning, x-rays, radiotherapy, nuclear accidents
- Erythema, edema, blisters, and pain
- Prolonged exposure can cause N/V/D, HA, fever, fatigue
Radiation
What burn depth is this?
- Pink/red
- Pain
Superficial
What burn depth is this?
- Blisters
- pink/red
- pain
- blanches
Superficial partial-thickness
What burn depth is this?
- Blisters
- waxy
- pink/cherry red
- edema
- no blanching
- pain around edges
- decreased sensation
Deep partial thickness
What burn depth is this?
- Leathery
- dry
- white,tan,brown, black eschar
- No blanching
- No pain
Full Thickness
How long do superfical burns take to heal? Do they leave scars?
3-7 days no scars
Most common superficial burn
Sunburn
Healing time for Superficial burns
1-2 wks
Superfical and superfical partial thickness burns are considered what type of burns?
Minor
How to treat minor burns
- Cool compress or cool water
- Provide analgesics
- Use lotion on intact skin
- Cleans with mild soap and tepid water
- Apply antimicrobial agent to non–intact skin
- Apply dressing if clothing is irritating
- Drink plenty of fluid
- Teach to observe for infection
How long do partial thickness burns take to heal and do they leave a scar? How is it treated? What is a challange associated with this type of burn?
- Healing can take 3-6 wks and can leave scaring
- Surgical debreidment or skin grafting can be required
- It is challenging to determine the true extent of the injury if it will heal or require surgical intervention
Full thickness burns require what? or what won’t happen?
Surgical excision and grafting, healing
Name the three phases of burn wound healing
Inflammation
Proliferation
Remodeling
Name this stage of burn wound healing
Begins immediately after injury, vasodialation, increase in capillary permeability
Inflammation phase
Name this stage of burn wound healing
2-3 days after burn, granulation tissue tissue forms, epithelial cells cover wound
Proliferation phase
Name this stage of burn wound healing
May last for years, collagen fibers reorganize, scars contract, fade
Remodeling phase
Amount of body burned that guides fluid resuscitation ____ for adults
less than or equal to 20%
Rule of Palm
Burns
1% to quickly estimate for scattered burns
Rule of nines
burns
Most common method with body broken into areas of 9% or multiples of 9
Underestimating TBSA burned can lead to what
pt going into shock and organ failure, burn shock
Overestimating TBSA burned can lead to what?
pt unable to tolerate and may develop pulmonary edema
Small burns can be ____ in older adults
Fatal
Factors that determine severity of burns
- Presence of inhalation injury
- Pt age
- PMHx
- Presence of contamination injury
- Anatomical location of burn
Important considerations for infants and children with burns
Be alert to s/s of child abuse when hx does not match injury
Important considerations for adolescents with burns
Foreward about edema or changes in body from injury response
When treating a pregnant woman with burns the nurse should be aware of what?
- Tx of mother threatens fetus
- relationship between percentage of TBSA involved and fetal maternal survival
Considerations for older adults with burns
- Greater risk for death
- may not tolerate fluid resuscitation and surgery
- Skin is less elastic and harder to heal
Rule of palm
1% to quickly estimate for scattered burns
Rule of nines
Most common method with body broken into areas of 9% or multiples
Lund and Browder classification
TBSA
Method of measuring TBSA burned used in a majority of burn centers. Takes into account surface area r/t age, are assigned to each body part.
Name percentages
Name percentages of body for TBSA
Head to toe
Head: 9%
Anterior: 18%
Posterior: 18%
each arm: 9%
Each hand: 1%
Perinium: 1%
Each thigh: 18%
Functional changes burn injuries are:
- Long-term morbidity
- Impaired function: burns to hands, feet, genitalia, perineum, and major joints
- Altered appearance: burns to face
- May require multiple lifelong plastic and reconstructive surgeries to maintain function
Burn injuries effect on respiratory system
- Inhalation injury
- Upperairway injury
- Lower airway injury
- Carbon monixide poisoning
- Airway management
What increases mortality risk in burn patients?
Inhalation injury
Most important factors in burn patients
- depth/extent of burn
- Patient age
- Inhalation injury
How long after burn injury can inhalation injury occur?
24-48hrs
Airway management for burn patients
- 100% humidified o2
- Cough/deep breathing
- Elevate HOB
- ET intubation
What should you always suspect in a burn patient?
That they were injured/trapped in an enclosed space or if they have face, neck, or chest burns.
The following are S/S of what?
- Facial burns
- Singed nasal and facial hairs
- Carbonaceous sputum (soot), hypersecretion
- Naso- or oropharynx erythema
- Excessive agitation/anxiety (hypoxia)
- Tachypnea, intercostal retractions, flaring nostrils
- Inability to swallow
- Hoarseness, grunting, brassy voice
- Rales, rhonchi, diminished breath sounds
Inhalation injury
The following are S/S of what?
* Headache
* Confusion
* N|V
* Diziness
* Dyspnea
* Chery red discoloration of skin
Carbon monoxide poisoning
THe following describes what?
- Occurs from massive fluid shift due to increased capillary permeability (first 8-36 hours)
- Electrolytes, water, plasma, proteins leak out into interstitial space called third spacing
- Blood becomes more viscous and slowed, decreasing oxygen delivery and cardiac output
Burn Shock
How to treat burn shock and what will happen if it is not done
w/o fluid resuscitation develop hypotension, tachycardia, decreased urine output, AMS, multi-organ failure
Lab findings in a burn patient in the Emergent phase
- Hyperkalemia-cardiac dysrhythmias
- Hyponatremia
- Metabolic acidosis
- Elevated Hematocrit
Describe FLuid remobilization/diuretic stage
- Occurs after 24-48 hours
- Capillary leak stops
- Edema fluid shifts from the interstitial spaces into the vascular space
- Blood volume increases leading to increased renal blood flow and diuresis
- Body weight returns to normal
GI & Metabolic effects of burn injuries
- Decreased nutrient absorption
- Decreased gastrointestinal motility
- Use of prokinetic agents, enteral nutrition support
- NG tube for long-term feeding and relieve initial distention
- Constant hypermetabolic state 1-3 years post injury
- Increased caloric need
Integumentary effects of burn injuries
- Loss of water secondary to evaporation
- Infection secondary to loss of skin integrity
- Difficulty maintaining body temperature
- Patient rooms and operating rooms kept at warmer temperature with specialized equipment
GU & Immune effects of burn injuries
- Glomerular filtration rates (GFR) reduced
- Urine output decreases
- Serum creatinine and blood urea nitrogen increase
- Myoglobinuria: Free hemoglobin and myoglobin from muscle damage could cause renal tubular necrosis; red/tea colored urine
- High risk for infection and sepsis
- SIRS (systemic inflammatory response syndrome) which may lead to sepsis
- Sepsis leading cause of death after 24 hours
Name the 6 P’s
- pulselessness
- pallor
- paresthesia
- pain
- paralysis
- poikilthermia (coolness)
Presence of one or more of the 6 P’s indicates what?
Compartment syndrome
Surgical incision through eschar to relieve pressure at bedside
Escharotomy
Incision extends through muscle, performed in OR used to treat compartment syndrome
Fasciotomy
Phases of burn injuries
- Emergent/resusitative
- Intermediate/acute
- Rehabilitive
What phase of burn injury is this?
- First 24-48 hrs
- Estimate extent of injury
- Implement fluid resuscitation
- Assess for shock and resp distress
- Determine if transport to burn center needed
Emergent/resuscitative
Goals of the emergent/resuscitative phase
- Secure airway
- Support circulation
- Comfort/pain management
- Maintain temp./prevent hypothermia
- Emotional support
Assessment of Emergent/resuscitative phase
- Time and cause of injury
- First aid treatment given
- Past medical hx
- Pre burn weight
- TBSA
What is phase of burn healing is this? and part of the phase is it?
- Airway and C-spine stabilization
- Breathing: 100% O2 non-rebreather
- Circulation: Neurovascular checks, elevate extremities
- Disability: Neurological checks
- Expose and examine: Extent & depth of burn & assoc. trauma
- Fluid resuscitation: 2 large bore IVs and start fluids (LR)
Primary survey done during the emergent/resuscitative phase
At what burn phase does the primary survey occur? What does it include?
Emergent/resuscitative phase
- Airway and C-spine stabilization
- Breathing: 100% O2 non-rebreather
- Circulation: Neurovascular checks, elevate extremities
- Disability: Neurological checks
- Expose and examine: Extent & depth of burn & assoc. trauma
- Fluid resuscitation: 2 large bore IVs and start fluids (LR)
What is phase of burn healing is this? and part of the phase is it?
- Circumstances of the injury
- Medical history & meds
- Last food and fluid intake
- Complete “head-to-toe” physical examination
- Calculate TBSA
- Cover the wounds
- Maintain body temp
- Pain medication
- Tetanus
- Labs (CBC, CMP, PT/aPTT, UA)
- ABG and/or carboxyhemoglobin
- 12-lead ECG, CK-MB, troponin
- Fluid Calculation
Emergent/resuscitative phase, secondary survey
What burn phase is the secondary survey part of? Name the parts of the secondary survey
- Circumstances of the injury
- Medical history & meds
- Last food and fluid intake
- Complete “head-to-toe” physical examination
- Calculate TBSA
- Cover the wounds
- Maintain body temp
- Pain medication
- Tetanus
- Labs (CBC, CMP, PT/aPTT, UA)
- ABG and/or carboxyhemoglobin
- 12-lead ECG, CK-MB, troponin
- Fluid Calculation
Is fluid resuscitation calculated from time of injury or time of arrival?
TIME OF INJURY
Calculation for fluid resuscitation for an adults and children 15yrs and older
- LR 2-4mL x weight(kg) x TBSA
- 1/2 of the volume in the 1st 8 hrs
- 1/2 of the volume in the following 16 hrs.
- Monitor pt response
- Urine OP goal: 0.5m;/kg/hr
Fluid resuscitation equation for children 14yrs old and below
- 3mL x weight(kg) x TBSA
- 1/2 of the volume in the 1st 8 hrs
- 1/2 of the volume in followinf 16 hrs
- Monitor pt response
- Urine OP goal of 0.5mL/kg/hr
Formula for fluid resuscitation of electrical injuries
- The same for ALL ages
- 4 mL x weight (kg) x TBSA
What happens after 24hrs of fluid resuscitation for burns pt
colloids are given based on labs i.e albumin or plasma
What is done to ensure urine OP is adequately measured?
Foley is placed
Indications of adequate fluid resuscitation
- Urine OP: 0.5mL/kg/hr (or) 1mL/kg/hr if myoglobin present
- SBP: Greater than 100 mmHg
- HR: less than 120 bpm
- CVP: 5-10 mmHg
- Pulm: lungs clear, pH WNL
- GI: abd soft, non-tender, no N|V, or ileus; bladder pressure less than 10 mmHg
- LOC: Clear, A&Ox4
Nursing Dx for emergent phase
- Ineffective airway clearance
- Impaired gas exchange
- Risk for fluid volume deficit
- Altered tissue perfusion
- Risk for hypothermia
- Acute pain
- Anxiety
Nursing interventions for Intermediate/acute phase
- Wound care
- Nutrition therapy
- Infection prevention
- Pain management
Wound management
- Hydrotherapy
- Debridement
- Dressing changes
Ointment that helps schar separation
Enzymatic ointment
What type of skin graft is this?
Temporary cadaver skin graft
allograft
What type of skin graft is this?
Temporary pig skin graft
Xenograft
What kind of skin graft is this?
patient’s own skin, most ideal permanent graft
Autograft
What type of skin graft is this?
patient’s own skin, most ideal permanent graft. More exposed areas (face, hands) more cosmetic appearance
Autograft-sheet graft
What type of skin graft is this?
patient’s own skin, most ideal permanent graft; Holes in them to expand
Autograft-mesh graft
What type of skin graft is this?
Cultured epithelial autograft, patient’s skin sample grown in lab
Cultured epithelial Autograft (CEA)
What type of skin graft is this?
Artificial skin of 2 layer silicone membrane
Integra
Name medications used for burn care
- Analgesia
- Sedation
- Anticoagulants
- Nutritional support
- GI support
This medication class is used to manage pain in burn patients
Analgesia
Give some examples of analgesics
Morphine sulfate (morphine)
Hydromorphone (Dilaudid)
Fentanyl (Sublimaze)
Ketamine (Ketalar)
Oxycodone (OxyContin, Tylox)
Methadone (Dolophine)
Nonsteroidal anti-inflammatory medications (ibuprofen or naproxen sodium)
This medication class is used to treat burn patients but decreasing anxiety, treating ETOH withdrawl, hypnotic agent, amnesic effects
Sedatives
Name some sedatives used to treat burn patients
Haloperidol (Haldol)
Lorazepam (Ativan)
Diazepam (Valium)
Midazolam (Versed)
Propofol (Diprivan)
Dexmedetomidine hydrochloride (Precedex)
This medication class is used to promote venous return and decrease risk for thromboembolism
Anticoags
Give some examples of medications given to burn patients for anticoag therapy
- Lovenox
- Heparin
Medications given to burn patients for nutritional support with rationale
Multivitamins-Promote wound healing
Zinc sulfate (zinc) and ferrous sulfate (iron)-Promote hemoglobin formation and cell integrity
Oxandrolone (Oxandrin)-Preservation of lean body mass and promotion of weight gain
Medications given to Burn patients for GI support
Zantac
Nexium
Protonix
Mylanta
Nystatin
Reglan
Miralaz
What topical medication/wound dressing is this?
Broad-spectrum and Candida coverage
Partial- and full-thickness burn wounds
¼-in.-thick application with roll gauze to cover; dressing changes every 12 hours
Cooling effect when applied; easy, painless application
Silver sulfadiazine or silvadene
Disadvantages of silvadene
May cause transient leukopenia; may also cause a wound film on partial-thickness burns, making it hard to assess healing
Nursing considerations for silvadene
Avoid in patients with a documented sulfa allergy. Avoid application to face.
What topical medication/wound dressing is this?
No gram-negative or fungal coverage
Partial-thickness burn wounds and grafts
Thin layer applied with a nonadherent gauze and an outer roll gauze; dressing changes every 24 hours
Easy, painless application; only once-per-day dressing change
Bacitracin
Disadvantages of Bacitracin
Not as effective on full-thickness burn wounds because of minimal penetration of eschar
Nursing considerations for Bacitracin
Best choice for use on a face, but left open to air. Use bacitracin ophthalmic ointment near and around eyes.
What topical medication/dressing is this?
Broad-spectrum, effective against Pseudomonas but has little anti-fungal coverage
Creamused on full-thickness burns to ears only; solution used on partial-thickness burn wounds and grafts
Cream isapplied 1/16 in. thick and left open to air. Solution is applied to nonadherent gauzeand roll gauze. Cream is changed every 12 hours; solution dressings are changed every 24 hours and may be wet down at 12 hours.
Creampenetrates eschar. Solution is only a once-per-day dressing change.
Mafenide acetate 10% cream or 5% solution
or
Sulfamylon Cream or Slurry
Disadvantages of Mafenide acetate 10% cream or 5% solution or Sulfamylon Cream or Slurry
Solution is awet-type dressing and may not be used on initial large burn wounds because it may cause hypothermia
Nursing considerations for Mafenide acetate 10% cream or 5% solution or Sulfamylon Cream or Slurry
Some patientsmay complain of stinging upon application to partial-thickness burn wounds. Frequent sensitivities noted.
What kind of topical treatment/dressing is this?
Broad-spectrum, effective against MRSA and fungus
Partial-thickness burn wounds, Stevens-Johnson syndrome (SJS), and patients with toxic epidermal necrolysis (TEN), donor sites
Some products are a wet application with sterile water and roll gauze. Dressing changes every 3–7 days; wet down with sterile water every 12 hours. Some products are applied dry and not wet down.
Dressing needs to be changed only every 4–7 days
Silver sheeting products
or
Acticoat, Silverlon, Mepilex
Name some disadvantages to Silver sheeting products or Acticoat, Silverlon, Mepilex for treating burns
Expensive. Burn wounds often need to be observed daily. Solution is a wet-type dressing and may not be used on initial large burn wounds because it may cause hypothermia.
Name nursing considerations for Silver sheeting products or Acticoat, Silverlon, Mepilex
This is best used in the patient with SJS/TEN as the dressing change process is extremely painful and wounds do not need to be observed daily. May also be of good use in the outpatient setting. Some patients may complain of stinging upon application. Do not use with normal saline because it will deactivate silver.
What type of topical treatment/dressing is this?
No antimicrobial effects and thus is often mixed with other ointments and/or creams
Full-thickness burn wounds (specifically digests collagen in necrotic tissue without harming intact tissue)
Thin layer applied with a nonadherent gauze and an outer roll gauze; dressing changes every 24 hours
Easy, painless application; only once-per-day dressing change; may help penetrate and soften eschar for debridement
Enzymatic cream
or
collagenase
Name some nursing interventions for Enzymatic cream or collagenase
Considered for use in patients with full-thickness burn wounds who are not candidates for the operating room because of age or medical condition; also considered for use in very small areas of full-thickness burns in an attempt to heal without surgery.
Nursing interventions when managing pain for burn patients
- Routine monitoring
- Use scheduled IV opioids instead of PRN, transition to PO when tolerated
- Avoid IM injections
- PCA appropriate for some clients
- Monitor for respiratory depression
- Administer pain medications prior to dressing changes or procedures
- Treat related anxiety
- Add nonpharmacologic methods for pain control
Infection prevention for burn patients
- Standard/contact precautions
- Restrict plants and flowers
- Limit visitors
- Use reverse isolation if prescribed
- Monitor for s/s of infection
- Use client designated equipment
- Administer antibiotics if indicated
Name some nursing DX for intermediate/acute phase
- Impaired skin integrity
- Risk for infection
- Altered nutrition: less than body requirements
- Impaired physical mobility
- Self-care deficit
- Disturbed body image
- Powerlessness
- Acute pain
- Anxiety
What phase of burn injury is this?
- Prevention of contractures and scars
- Splinting across major joints
- Specialty pressure garments to prevent hypertrophic scarring
- ROM to enhance mobility
- Mental health treatment for PTSD, depression, anxiety, body image disorder
- Client’s successful resumption of work, family, and social roles
Rehabilitative phase
Nursing interventions r/t mobility for burn patients
- Maintain correct body alignment
- Active and passive range of motion
- Ambulate
- Positioning and pressure dressings to prevent contractures
- Monitor high risk areas for pressure sores
Nursing dx for rehabilitative phase
- Activity intolerance
- Impaired physical mobility
- Disturbed body image
- Moral distress
