Week 7 - Burns Flashcards
___ are known to be one of the most complex traumas
Burns
Why are burns often the most complex traumas
they usually involve multiple systemic trauma (psychosociophysio)
the mechanism of injury is also varied: it can be thermal, radioactive, electrical, chemical, and a mixture of mechanisms
Where do most burns occur
in the home
Which people are more likely to get burn injuries
young children
older adults
disabled patients
men > women
Layers of skin from superficial to deepest
- Epidermis
- Dermis
- Subcutaneous Tissue
In what ways does the body use the skin
as a protective barrier from outside elements
helps with thermoregulation
gives us our good looks and recognition
helps with vitamin D synthesis
Epidermis
most superficial layer of skin
contains cells that produce pigment and protect the immune system
Dermis
second most superficial layer of skin and the largest
contains nerve endings, oil and sweat glands, and hair follicles
Subcutaneous Tissue
deepest layer of skin
made up of fat, connective tissue, and larger blood vessels
What is some education nurses can provide to prevent burns
information on:
sun exposure
supervising children
smoke and carbon monoxide detectors
water heat temperature checks
smoking in bed
curling irons
running cords under rugs
Burns are ____
preventable!
Nursing Goals Related to Burns
- PREVENTION
- Lifesaving measures for the severely burned person
- Prevention of disability and disfigurement through early specialized care - really impacts physical self
- Rehabilitation through reconstructive surgery and programs - prevent contractures and ability to move muscles
First Degree Burns
superficial injuries that often involve the outermost layer of the skin (Epidermis)
ex: Sunburn
Second Degree Burns
involve the entire epidermis and portions of the dermis
painful with blisters
can be felt and most painful feeling burn
a deep 2nd degree hurts more than a 2nd superficial
Third Degree Burn
full thickness
destruction of the epidermis, dermis, and underlying tissue - lack of sensation occurs
cannot be felt
Fourth Degree Burn
Full thickness
deep burn necrosis - extends into deep tissue, muscle, and bone
cannot be felt
TBSA
Total Body Surface Area
Methods of estimation on how much of the body has been burned
Rule of Nines
the most common method of estimating total body surface area
based on anatomic regions split into percentages based on if you are a child or an adult
What are the percentages of the anatomic regions for a child in the rule of nines
18% head 18% front 18% back 14% left leg 14% right leg 9% left arm 9% right arm
What are the percentages of the anatomic regions for an adult in the rule of nines
9 % head 1% neck 18% front 18% back 18% left leg 18% right leg 9% left arm 9% right arm
What is the Palmer Method & Lund and Browder Method
two alternative measures for estimating TBSA like the rule of nines
A burn of ___% or more becomes a systemic problem and are considered major burns
30%
What is the systemic response to a major burn like
Burn of 30%+ –> release of cytokines and other mediators into systemic circulation –> Fluid shifting and shock states –> Potential hypoperfusion and organ hypofunction
What sort of secondary injuries and issues can occur from major burns (30%+)
fluid and electrolyte shifts
cardiovascular effects
pulmonary injury: upper and lower airway, CO poisoning, restrictive defects
Renal and GI alterations
Immunologic alterations
Effect on thermoregulation
What are the phases of burn injury
- Emergent or Resuscitative Phase
- Acute or Intermediate Phase
- Rehabilitation Phase
What is the time period for emergent or resuscitative phase of burn injury
onset of injury to completion of fluid resuscitation (since they are risk for hypovolemia)
What is the time period for the acute or intermediate phase of a burn injury
from the beginning of diuresis until wound closure
What is the time period for the rehabilitation phase of burn injury
from wound closure to return to optimal physical and psychosocial adjustment (think of the psychological and skin graft self concept effects)
What on the scene care is done during the emergent or resuscitative phase of a burn injury
prevent injury to rescuer - gotta help yourself before helping others
stop the injury: extinguish flames, cool the burn, irrigate chemical burns
ABCs: Establish airway breathing and circulation
Start O2 and large bore IV fluids
Remove restrictive objects (since people swell with burns) and cover the wound
Do assessment surveying all body systems and obtain a hx of the incident and pertinent patient
What is important to keep in mind with on the scene burn care if the patient may have fallen or had an electrical injury
to treat them as potential cervical spine injuries/patients
What care is done during the emergent or resuscitative phase
pt moved to ED
fluid resuscitation begins
foley catheter inserted
NG tube if indicated for suction
pt stabilized and condition continually monitored
ECG
address pain
psychosocial considerations and emotional support give to patient and family
Patients with burns exceeding what percentage should have an NG tube inserted and placed to suction
20-25%
Patients with electrical burns need to have a ____
ECG
When addressing pain for an emergent or resuscitative phase burn, only give meds how?
Via IV Administration
Acute or Intermediate Phase of burn injuries occurs ___ to ___ hours after injury
48-72 hours after injury
Management in the Acute or Intermediate Phase
continue assessment, maintain resp and circ support, fluid and electrolyte balance, GI and renal function
Prevent infection
Burn wound care, pain management, modulation of hypermetabolic response
Early positioning and mobility
Watch for hypovolemia
____ is begun at all stages of burn injuries technically
rehabilitation
What is the focus and management like in the Rehabilitation Phase of Burn Injuries
Focus is on wound healing, psychological support, self image, lifestyle, and restoring maximal functional abilities
Patient may need reconstructive surgery to improve fxn and appearance
Vocational, psychological counseling, and support groups may assist the patient
Include family as indicated
What nursing interventions of the burn patient are done in the acute phase
Restoring fluid balance
preventing infection
modulating hypermetabolism
promoting skin integrity
relieving pain and discomfort
promoting mobility
strengthening coping strategies
What nursing interventions are done for the burn patient in the intermediate and rehabilitation phases
strengthening coping strategies
support patient and family processes
monitoring and managing complications
T/F: Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency burn care?
True - think of the ABCs
Why is fluid resuscitation so important in burn patients
Fluid shifts occur from intravascular to interstitial d/t the inflammatory response
move from cells to other body parts and fluid loss occurs causing general dehydration s/s intracellularly
fluid also evaporates from a burn injury
Management of Fluids / Fluid Replacement is required in adults with burns greater than ___%; in children with burns greater than ___%; and any burn in ages less than ___ or greater than ___
adults - 20%
children 10%
in any burn less than 2 yo or greater than 60 yo
Fluid replacement goals for adult burns include a BP of what? A pulse of what? and urinary output of what?
BP >100 systolic
Pulse <110
UO >30 cc/hr adults
What is usually the basis for the formula for fluid replacement with burns
TBSA (total body surface area)
How fast are fluids usually instilled for burn fluid resuscitation
50% of the fluids are given in the first 8 hours - since most fluid lost, shifts, and evaporation occur then
the next 50% of fluids are given in the 16 hours following that (25% given in first half of the 16 and 25% given in second half)
What may be used for fluid resuscitation of a burn victim
Usually its an isotonic solution like lactated ringers solution
May replace PRBCs with blood loss so blood transfusion potential exists
Other Criteria for Adequate Fluid Resuscitation
appropriate sensorium
appropriate BP and pulse
relief of nausea and ileus after 24 hours
Signs and Symptoms of Fluid Loss/Burn Shock
decreased BP
decreased LOC
decreased UO
Increased pulse
Increased Hct
edema at burn site
Na deficit
K excess (cell destruction)
Metabolic acidosis
Management of Shock - Fluid Resuscitation
maintain a BP of greater than 100 sys and UO of 30-50 mL/hr
Maintain serum sodium at near normal levels
Pick your fluid based on several formulas like consensus, evans, brooke army, parkland baxter, hypertonic saline formulas
What are some s/s of the fluid and electrolyte shifts occurring in the burn emergent phase
generalized dehydration
reduced blood volume and hemoconcentration
decreased UO
trauma causes release of K into extracellular fluid - Hyperkalemia
sodium trapping in edema fluid and shifts into cells as K is released - Hyponatremia
Metabolic Acidosis
S/S of fluid and electrolyte shifts in the acute/intermediate phase
fluid re enters the vascular space from the interstitial space
hemodilution
increased UO
Na loss with diuresis and due to dilution as fluid enters vascular space - Hyponatremia still
K shifts from extracellular fluid into cells - Potential Hypokalemia
Metabolic Acidosis
Formulas are only a guide for burn care fluid resuscitation. How often must the patient’s response to fluid therapy (HR, BP, UO) be evaluated?
At least hourly
What is involved in burn wound care
- Wound cleaning with hydrotherapy, antibacterial products, and wash solutions
- Use of numerous topical agents - very common - antibacterial creams for example
- Wound debridement: autolytic, mechanical, surgical
- Wound dressing, dressing changes, and skin grafting / monitoring
What is considered one of the most severe forms of acute pain
Burn pain
Pain for burn injuries occurs when else other than just with the burn itself
pain accompanies care and treatments such as wound cleaning and dressing changes
Types of Burn Pain
Background or Resting Pain
Procedural Pain
Breakthrough Pain
One of the hardest areas of burn wound care is
Managing the pain - it is hard to have under control
Methods of Pain management in burn victims
Analgesics - IV during emergent/acute phases, Morphine, Fentanyl, Other Drugs
Role of Anxiety in Pain - Relieve Anxiety
Effect of Sleep Deprivation on Pain - Promote sleep + environment
Nonpharmacologic Measures
What is important to know about nutrition and burns
Burn injuries produce profound metabolic abnormalities
Patients with burns have great nutritional needs related to stress response, hypometabolism, and for wound healing
The goal of nutritional support for burn patients is what
to promote a state of nitrogen balance and match nutrient utilization
Nutritional support of burn patients is based on what
patient pre burn status AND % of TBSA burned
What is the preferred route of nutritional support for burn patients?
Enteral route; A jejunal feeding is often used to maintain nutritional status with a lower risk of aspiration in a patient with poor appetite, weakness, or other problems
What is some important aspects of home care management of the burn patient once they return home
mental health
skin and wound care
exercise and activity
nutrition
pain management
sexual issues
pulmonary care
psychological support of patient and family
patient and family education
restoration of function
thermoregulation and clothing
(VERY HOLISTIC APPROACH WHEN CARING IN THE HOME)
What is the recommended fluid resucitation amount for children
6 mL/kg/% burned
