Week 4 Burns Flashcards
Problems resulting from burns
fluid and protein loss, changes in metabolic, endocrine, respiratory, cardiac, hematologic and immune function
Healing of burns to the epidermis
Can grow back
epidermal cells surrounding sweat and oil glands and hair follicles extend into dermal tissue and regrow to heal partial thickness wounds
Does the epidermis have blood vessels?
no
What is found in the dermis?
blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous glands, and sweat glands
Healing of burns to the dermis
if any more than the first 3rd is burned, the skin can no longer restore itself
Temperature skin can tolerate without injury
104
Temperatures above what cause rapid cell destruction
158
Superficial burn description
Pink to red, mild edema, painful, no blisters, no eschar, 3-6 day healing time, ex- sunburn
Superficial partial thickness burn description
pink to red color, mild to mod edema, painful, blisters present, no eschar, 2 week healing time, ex- scalds, flames
Deep partial thickness burn description
Red to white color, mod edema, painful, blisters unlikely, soft dry eschar, 2-6 week healing time, possible grafts, ex- flame, grease, and chemicals
Full thickness burn description
Black, brown, yellow, red or white color, severe edema, intermittent pain, no blisters, hard and inelastic eschar, weeks to months to heal, requires grafts, ex- flame, tar, grease, electricity
Deep full thickness burn description
Black color, no edema, no pain, no blisters, hard and inelastic eschar, weeks to months healing requiring grafts, ex- flame, electricity, grease, chemicals
Fluid shift occurring with burns
3rd spacing occurs in the first 12 hours until 24-36 hours
Imbalances in fluids, electrolytes and acid-base
Hemoconcentration in burns
elevated blood osmolarity, hematocrit, and hemoglobin from vascular dehydration and increases blood viscosity
Fluid remobilization
begins 24 hours after injury (when fluid shift stops) diuresis increases to remove excess fluid and edema subsides
Cardiac Changes Resulting from Burn Injury
Initially HR increases and CO decreases because of the initial fluid shifts and hypovolemia
Burns and GI changes
decreased motility and blood flow, peristalsis/paralytic ileus, ulcer development
Prevention of ulcer development after a burn
give H2 blockers or PPI’s early
Inflammatory compensation after a burn
can trigger healing
causes problems with fluid shift
helpful in the short term
Sympathetic nervous system response to burns
Stress response: increased thirst, HR and RR, catecholamine, aldosterone and metabolic rate, slowed GI motility, release of glycogen stores, fluid retention, vasoconstriction, decreased urine and hematocrit positive stools.
Factors that increase death from burns
age over 60
over 40% TBSA burned
inhalation injury
Factors that improve outcome from burns
vigorous fluids, early wound excision, improved critical care monitoring, early enteral nutrition, antibiotics, and the use of burn centers
Resuscitation/ emergent phase
occurs after injury until 24-48 hours
Priority care in the resuscitation/ emergent phase
Airway, circulation (fluid replacement), comfort with analgesics, prevent infection, maintain body temp and provide emotional support.
General management for all burns
Assess airway, Administer O2, Cover with a blanket, Keep NPO, Elevate extremities, Obtain VS, IV access, and begin fluid replacement, Administer tetanus for prophylaxis, Perform a head-to-toe assessment.
Electrical Burns Management
Smother any flames, Initiate CPR, and Obtain an ECG
Signs of pulmonary injury
hoarseness, brassy cough, drool or difficulty swallowing, audible wheezes or stridor on exhalation
Cardiovascular assessment in burns
Monitor edema, measure central and peripheral pulses, BP, cap refill, and pulse ox
Rate of fluid resuscitation
whatever rate is needed to have urine output greater than 30-50 ml/hour
S/Sx of paralytic ileus
nausea, vomiting, and abdominal distention
Hemoglobin normal and what is expected after a burn
12-16g/dL (women) 14-18g/dL (men) Elevated as a result of fluid volume loss
Hematocrit normal and what is expected after a burn
37%-47% (women) 42%-52% (men) Elevated as a result of fluid volume loss
BUN normal and what is expected after a burn
10-20mg/dL Elevated as a result of fluid volume loss
Glucose normal and what is expected after a burn
70-105mg/dL Elevated as a result of the stress response and altered uptake across injured tissues
Na+ normal and what is expected after a burn
136-145mEq/L Decreased; sodium is trapped in edema fluid and lost through plasma leakage
K+ normal and what is expected after a burn
3.5-5.0mEq/L Elevated due to disruption of the sodium-potassium pump, tissue destruction, and RBC hemolysis
Cl- normal and what is expected after a burn
98-106mEq/L Elevated as a result of fluid volume loss and reabsorption of chloride in urine
PaO2 normal and what is expected after a burn
80-100mmHg Slightly decreased
PaCO2 normal and what is expected after a burn
35-45mmHg Slightly increased from respiratory injury
pH normal and what is expected after a burn
7.35-7.45 Low as a result of metabolic acidosis
Carboxyhemoglobin normal and what is expected after a burn
0%-10% Elevated as a result of inhalation of smoke and carbon monoxide
Total protein normal and what is expected after a burn
6.4-8.3g/dL Low; protein exudate is lost through the wound
Albumin normal and what is expected after a burn
3.5-5.0g/dL Low; protein is lost through the wound and through vascular membranes because of increased permeability
The priority problems in the resuscitation/ emergent phase for Pts with burns greater than 25% of the TBSA
Potential for inadequate oxygenation Hypovolemic shock Potential for organ ischemia Pain Potential for ARDS
When does upper airway edema become pronounced?
8-12 hours after fluid recuscitation
Vigorous suctioning is performed after chest physiotherapy and aerosol treatments
Ways to monitor for gas exchange
ABGs, assessing for cyanosis, disorientation, and increased HR
Priority intervention for b. Preventing Hypovolemic Shock and Inadequate Oxygenation
Rapid infusion of IV fluids (fluid resuscitation)
Best practices for fluid resuscitation
Administer one half of the total 24-hour prescribed volume within the first 8 hours post burn and the remaining volume over the next 16 hours, monitor VS, urine and fluid status hourly
Acute phase of burn injury time frame
36-48 hours until wounds are closed, begins when diuresis is noted
Leading cause of death during acute phase of resocery
infection
Priority problems for patients with burn injuries greater than 25% TBSA in the acute phase of recovery
Wound care management Potential for infection Excessive weight loss Reduced mobility Reduced self-image
Nursing interventions for maintaining patient mobility
neutral body position to prevent contractures, ROM 3x daily, ambulation, pressure dressings
Opioid administration during the resuscitation phase
IV only
Burn % of severe burns
over 20% TBSA
Poisonous bi-product of burning material
carbon monoxide
Healing time of superficial partial thickness burn
1-3 weeks
Chief characteristics of superficial partial thickness burn
blister formation
epidermis is gone and the upper third of the dermis is gone
Deep partial thickness burn and hypoxia
wound can progress to a full thickness
Deep partial thickness burn healing time
1-3 months
Zone of hyperemia
least damaged area of the burn, heals in 3-5 days
Zone of stasis
where tissue perfusion is compromised, vasoconstriction and thrombosis with lots of debris, can regenerate with tx
Zone of coagulation
permanent burn injury with cell death
Burn criteria for going to a burn center
Partial thickness burns >= 20% TBSA in patients 10 - 50 years old or >=10% TBSA in children < 10 or adults > 50
Full-thickness burns >= 5% TBSA in any age.
Patients with partial or full-thickness burns of the hands, feet, face, eyes, ears, perineum, and/or major joints
Electrical, chemical, inhalation, trauma, co-morbid illnesses
Body temperature after a burn injury
often develop a low grade fever, if the fever is high, an infection may be present (hypothalamus regulates temp and is not working well)
Immune response to burn
severe causes bone marrow suppression, shorter RBC lifespan, decreased/ ineffective WBC production
Rehabilitative phase of burn injury
begins after wound closure and can last a lifetime
Pulmonary fluid overload/ pulmonary edema
can occur even if no damage to lungs occurred due to histamine release and inflammatory response, can also be from over hydrating by IV
Vasoconstriction after a burn
occurs initially, body is trying to shunt blood from burned area and there is no blood there, may lead to vessel thrombosis (causing ischemia)
Vasodilation after a burn
occurs after vasoconstriction, leads to capillary leak/ 3rd spacing
How to manage hyperkalemia
give fluids so kidneys will get rid of it, kayexalate, or insulin + dextrose 50%
Common cause of death to burn patients in the emergent phase
shock, need to keep circulating blood volume up
During the initial stage of burns, where does the primary fluid imbalance/ shift occur?
from the plasma to the interstitial space
How do we know if fluid resuscitation is working?
Urine output is #1
BP is #2
Myoglobin release
released from damaged muscle, it can circulate to the kidneys and clog them
Background burn pain
pain from the actual burn and damage to your body
Why does hyponatremia develop in burn patients?
Displacement of sodium in edema fluids and loss through denuded areas of skin
How often are wound dressings changed?
cleaned and dressed daily or more frequently depending on the amount of exudate or weeping or if they have an infection (with infection, it’s 2x a day)
Most common surgical management for burn injury
skin grafting
How to calculate how much fluid to give
wt in kg x TBSA % burned
