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Nursing 272: Final Semester > Unit 3: Burns: Emergent Phase > Flashcards

Unit 3: Burns: Emergent Phase Flashcards

1
Q

Starting Emergent Phase of Burns

A

although the emergent phase does not officially begin until the patient reaches the hospital, it is vital that basic burn care is initiated at the scene

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2
Q

Initial priorities for the emergency personnel on the scene

A
  • stopping the burn process
  • airway management
  • fluid resuscitation
  • prevention of hypothermia
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3
Q

What are the 2 key pieces of information that are essential in the handoff report?

A
  • the circumstances surrounding the injury

- the total amount of fluid the patient received during transport

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4
Q

What is the primary goal during the emergent phase?

A
  • resolve immediate life-threatening issues resulting from the burn injury
  • priorities: baseline diagnostic evaluation, airway management, fluid resuscitation, pain management, prevention of hypothermia, and initiation of wound care
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5
Q

Priorities for the Emergent Phase Care

A
  • baseline diagnostic evaluation
  • airway management
  • fluid resuscitation
  • pain management
  • prevention of hypothermia
  • initiation of wound care
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6
Q

Diagnostic Studies

A
  • Complete blood count (CBC)
  • Serum glucose
  • Creatinine
  • Blood Urea Nitrogen (BUN)
  • Prothrombin time/activated partial thromboplastin time (PT/aPTT)
  • International normalized ratio (INR)
  • Complete metabolic panel (CMP)
  • Arterial Blood Gases (ABGs)
  • ECG
  • Chest x-ray
  • Toxicology screen
  • Serum carboxyhemoglobin level on inhalation injuries; Bronchoscopy indicated for definitive diagnosis
  • ECG for electrical injuries
  • Baseline ECK, Troponin, and Creatine-kinase (CK-MB)
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7
Q

Fluid and Electrolyte Changes in the Emergent Phase

A

> Generalized dehydration
-plasma leaks through damaged capillaries (third spacing) and into interstitial spaces

> Reduction in blood volume
-secondary to third spacing, blood pressure falls, and CO diminished

> Decreased urinary output
-secondary to fluid loss and decreased renal blood flow

> Hyperkalemia
-massive cellular trauma causes the release of potassium into extracellular fluid

> Hyponatremia
-large amounts of sodium are lost to third spacing, wound drainage, and shifting into cells as potassium is released

> Metabolic Acidosis
-loss of bicarbonate ions accompanies loss of sodium

> Elevated hematocrit
-plasma is lost to extravascular spaces, leaving the remaining blood very viscous

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8
Q

Airway Maintenance

A
  • assessment of airway takes top priority
  • 100% oxygen w/ non-rebreather mask w/ all burn injuries
  • patients at risk for intubation: facial burns, changes in voice (hoarseness), carbon noted in sputum, and injury associated with a fire in an enclosed space
  • essential to secure the endotracheal tube with umbilical twill or commercially prepared endotracheal tube holders and not adhesive tape because tape does not stick to the burned face and does not allow for swelling
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9
Q

Fluid Resuscitation

A
  • crucial to the survival of the patient who has suffered a burn of 20% TBSA or greater
  • objective: maintain tissue perfusion and organ function; avoiding potential complications of inadequate or excessive fluid resuscitation
  • inadequate leads to organ failure and death
  • IV resuscitation is initiated in adults at 20% TBSA
  • if possible, consult burn center prior to resuscitation
  • fluid of choice: Lactated Ringers (LR)
  • IV access should be obtained ASAP
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10
Q

Fluid of choice for resuscitation

A

-Lactated Ringers (LR)

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11
Q

Intravenous Access

A
  • essential and be obtained ASAP
  • two large-bore (No. 20 gauge or larger) peripheral IV catheters are placed through unburned skin
  • if no such area exists, the IV lines can be inserted through burned tissue but must be well secured
  • if obtaining a peripheral IV catheter is extremely difficult, an intraosseous line is acceptable
  • major burns often require a central venous catheter b/c of the large volumes of fluid that need to be administered
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12
Q

Fluid Resuscitation Calculation

A
  • 2 to 4 mL of lactate ringers x kg x %TBSA
  • Half of the total volume is given in the first 8 hours post burn and the remaining half is given over the next 16 hours
  • resuscitation begins from the time the burn injury occurred; Ex: if EMS were unable to obtain an IV line on the scene and the patient arrives at the ED 2 hours post injury, fluid volume should be adjusted, and the initial 8 hour volume must now be infused over 6 hours
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13
Q

Examples of Fluid Resuscitation

A

Patient weight: 70 kg
TBSA burned: 50%

> 2 mL x 70kg x 50 = 7000 mL of LR in the first 24 hours

  • First 8 hours: 7000 divided by 2(half is given first 8 Hours) = 3500
  • rate: 3500/8 = 438 mL/hr
  • Next 16 hours = 3500
  • rate: 3500/16 = 218 mL/hr
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14
Q

During Fluid Resuscitation

A
  • indwelling urinary catheter is placed to monitor urine output; reliable indicator of adequate fluid resuscitation
  • urine output maintained at 0.5 mL/kg/hr
  • if myoglobin present in urine, output should be maintained at 1 mL/kg/hr until clearing of the urine occurs to prevent the development of acute renal failure
  • diuretics not indicated during emergent phase
  • if urine output drops, rate of fluid administration is increased
  • monitor HR, BP, central venous pressure, serum chemistries, hemoglobin, and hematocrit
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15
Q 
Connection Check: Using the resuscitation guidelines, the nurse determines that a patient requires a total of 12 L of fluid in the first 24 hours post-injury. How much of the total volume needs to be given within the first 8 hours?
A. 4,000 mL Lactated Ringers
B. 6000 mL Lactated Ringers
C. 8000 mL Lactated Ringers
D. 10000 mL lactated Ringers
A

B. 6000 mL lactated ringers

>half of the fluid is given within the first 8 hours

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16
Q 
Connection Check: When hemodynamic status is monitored in a patient w/ a burn injury, what amount of urine output indicates adequate fluid resuscitation?
A. 0.5 mL/kg/hr
B. 1 mL/kg/hr
C. 2 mL/kg/hr
D. 3 mL/kg/hr
A

A. 0.5 mL/kg/hr

17
Q

Prevention of Hypothermia

A
  • commonly seen in patients with burns b/c the skin, their primary insulation, is no longer intact
  • keep patient covered at all times
  • closely monitor temperature
  • ambient room temperature usually increased to decrease heat loss
18
Q

Wound Care

A
  • not the first priority
  • wound covered with clean, dry blankets to prevent hypothermia
  • initiation of wound care may be delayed for several hours until the patient is stabilized b/c there are more life-threatening concerns
19
Q

Pain Management

A
  • A burn is one of the most painful injuries an individual can sustain
  • IV narcotics (morphine) are used for initial management of pain
  • intramuscular route is avoided b/c there may be impaired medication absorption d/t an edema formation and decreased peripheral perfusion
  • pain medication is administered intravenously in doses no larger than those needed to manage pain
  • monitor for signs of respiratory depression when given large doses of pain medication
20
Q 
Connection Check: The nurse recognizes which diagnostic test as most sensitive in a patient with a suspected electrical burn injury?
A. Arterial blood gas (ABGs)
B. CK-MB levels
C. Echocardiogram
D. Serum carboxyhemoglobin
A

B. CK-MB

>electrical burns affect the heart; affect electrical conduction system

21
Q

Connection Check: Which intervention is the priority for the patient during the emergent phase of burn management?
A. Application of silver sulfadiazine cream
B. Use of clean, dry sheets and warm blankets
C. Initiation of wet normal saline dressings
D. Maintaining the injured area open to air

A

B. Use of clean, dry sheets and warm blankets

22
Q

Medications in the Emergent Phase of Burns

A
  • given to treat common concerns or potential complications facing the burn patient
  • anticoagulation therapy, nutritional support, gastrointestinal motility, anxiety, and depression
  • in addition to pain management
23
Q

Nursing Management: Assessment and Analysis

A 
>during the emergent phase, priority assessments focus on immediate life-threatening injuries; airway management (particularly w/ suspected inhalation injury), fluid volume status, temperature control, and pain management
Clinical Manifestations:
-facial burns
-naso- or oropharynx erythema
-hoarseness, grunting
-carbonaceous (soot) sputum
-dyspnea
-wheezing
-tachypnea
-intercostal retractions and flaring nostrils
-elevated carboxyhemoglobin levels
-tachycardia
-hypotension
-confusion, agitation, changes in LOC
-decreased urine output
-hypothermia
-headache
-complaints of pain
24
Q

Clinical Manifestations of Emergent Phase

A
  • Facial Burns
  • Naso or Oropharynx erythema (redness)
  • Hoarseness, grunting
  • Carbonaceous (soot) sputum
  • Dyspnea
  • Wheezing
  • Tachypnea
  • Intercostal retractions and flaring nostrils
  • Elevated carboxyhemoglobin levels
  • Tachycardia
  • Hypotension
  • Confusion, agitation, changes in LOC
  • Decreased urine output
  • Hypothermia
  • Headache
  • Complaints of pain
25
Q

Nursing Diagnoses

A
  • Ineffective airway clearance r/t airway edema secondary to injury from heat and/or chemicals
  • Impaired gas exchange r/t carbon monoxide poisoning, smoke inhalation, and upper or lower airway obstruction
  • Risk for fluid volume deficit r/t hypovolemia d/t third spacing of fluids and inadequate fluid resuscitation
  • Altered tissue perfusion r/t decreased cardiac output
  • Risk for hypothermia d/t altered skin integrity
  • Risk for infection d/t loss of skin’s protection and the burn injury
  • Acute pain secondary to the burn injury
  • Anxiety r/t fear surrounding the burn injury
26
Q

Nursing Assessments for the Emergent Phase of a Burn

A
  • Breath sounds, respiratory rate, and indicators of inhalation injury
  • Oxygen saturation, ABGs, and carboxyhemoglobin levels
  • Face and neck for burns, singed nasal and/or facial hair, and signed eyebrows/eyelashes
  • Upper airway
  • Changes in voice, hoarseness, and swallowing difficulty
  • Vital signs
  • Urine Output
  • Pain
  • Anxiety
  • Burn wound size and depth
27
Q

Assessments: Breath sounds, respiratory rate, and indicators of inhalation injury

A
  • edema and irritation of the airway may develop secondary to damage caused by heat and chemical irritants as evidenced by hypoxemia, rhonchi, stridor, changes in voice (hoarseness), and/or dyspnea
  • inhalation injuries may impair respiratory function, leading to decreased ventilation and changes in rate and effort, resulting in lower oxygention
28
Q

Assessment: Oxygen saturation, ABGs, and carboxyhemoglobin levels

A
  • the oxygen molecules may be saturated by carbon monoxide instead of oxygen, which is evident only through measurement of carboxyhemoglobin levels
  • carbon monoxide binds to the hemoglobin molecule w/ an affinity of 200 times greater than that of oxygen
  • tissue hypoxia results when carbon monoxide levels are above normal
  • results of ABGs provide info r/t the acid-base status
29
Q

Assessment: Face and neck for burns, singed nasal and/or facial hair, and singed eyebrows/eyelashes

A

edema and irritation of the airway may develop secondary to damage caused by heat and chemical irritants as evidenced by hypoxemia, rhonchi, stridor, changes in voice (hoarseness), and/or dyspnea

30
Q

Assessment: Upper airway

A
  • damage and irritation caused by the heat and chemical irritants in smoke may cause the airway to appear red and edematous
  • mouth and/or airway may also appear black because of soot
31
Q

Assessment: Changes in voice, hoarseness, and swallowing difficulty

A

-damage from the heat and chemical irritants in smoke may cause edema and irritation, resulting in changes in the voice, hoarseness, and/or difficulty swallowing

32
Q

Assessments: Vital Signs

A
  • blood pressure may be low and pulse elevated secondary to potential hypovolemia d/t significant fluid losses and shifts
  • pulse may be elevated secondary to increased work of breathing with inhalation injuries, pain, and fear/anxiety
  • b/c of impaired skin integrity, temperature may be decreased
  • patient shivering further accelerates metabolic rate and exacerbate tachycardia
33
Q

Assessment: Urine Output

A

-indicators or inadequate resuscitation and development of hypovolemia may be evidenced by urine output less than 0.5 mL/kg/hr

34
Q

Assessment: Pain

A

pain will be noted in areas of partial-thickness burns b/c nerve endings are exposed

35
Q

Assessment: Anxiety

A

anxiety levels may be high b/c of the appearance of the burn wound and exposure to trauma

36
Q

Assessment: Burn Wound Size and Depth

A

-although wound treatment is not a priority in this phase, estimations of % TBSA burned and wound depth are required to determine fluid resuscitation

37
Q

Nursing Actions

A
  • Place patient on 100% humidified oxygen or assist w/ intubation if necessary
  • Trend ABG values and carboxyhemoglobin levels
  • Elevate HOB to allow for better oxygenation
  • Maintain emergency airway (intubation and tracheostomy) trays at bedside
  • Assist w/ intubation as necessary
  • Ensure securement of the endotracheal tube if the patient is intubated
  • Monitor mechanically ventilated patients closely for signs of respiratory compromise
  • Place two large-bore IV catheters and begin fluid resuscitation with Lactated ringers (LR)
  • Roughly estimate the % TBSA burned and patient weight in kg
  • Cover wounds with a clean, dry sheet
  • Institute warming measures in the form of blankets or other external heat sources
38
Q

Nursing Teachings

A
  • Immediately report difficulty breathing and/or swallowing
  • Instruct to cough and deep breathe every hour; clears airway and mobilizes secretions
  • Signs of inhalation injury
  • Explain all procedures to the patient and family in clear and simple terms
  • Importance of maintaining a warm environment
  • Risk factors that increases chances of infection
39
Q

Evaluating Care Outcomes

A

> at the end of the emergent phase, the outcomes include:

  • absence of respiratory distress
  • appropriate fluid resuscitation manifested by stable vital signs, adequate urine output, temperature regulation, and effective pain management
  • in the event of inhalation injuries, stabilization of the airway and sufficient oxygenation
  • adequate urine output with an expected outcome of 0.5 mL/kg/hr, with the recognition that any decrease in urine output below the recommended level must be immediately reported
  • b/c patients with burns lose the ability to effectively manage their temperature, nurse anticipates normothermia w/ appropriate interventions
  • adequate pain and lessened anxiety

Nursing 272: Final Semester (79 decks)

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