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NURS 3512 - Class 7-12 > Week 8 - Burns > Flashcards

Week 8 - Burns Flashcards

1
Q

why is skin integrity important

A
  • first line of defense for the body
  • acts as a barrier from the external elements, bacteria, and viruses
    = impairement of skin integrity = body vulnerable to hosts of potential complications & infection
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2
Q

what are some functions of the skin (3)

A
  • thermoregulates
  • helps regulate fluid & electrolyte balance
  • communicates w brain thru nerves to identify sensory factors like pain & temp
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3
Q

what are 5 types of burns

A
  • thermal
  • chemical
  • electrical
  • smoke & inhalation
  • cold thermal
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4
Q

what are thermal burns

A
  • burns caused by flame, flash fire, scalding, or contact w hot objects
  • most common type of burn injury*
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5
Q

what are chemical burns

A
  • burns result from tissue injury & destruction from acids, alkali, and organic compounds
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6
Q

chemical burns can effect.. (2)

A
  • the skin

- eyes

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7
Q

what are some examples of causes of chemical burns (4)

A
  • household cleaners
  • phenols
  • heavy infustrial cleaners
  • fertilizers
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8
Q

are alkali or acid burns more difficult to manage? why?

A
  • alkali

- they are not neutralized by tissue fluids as readily as are acid substanced

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9
Q

what are smoke & inhalation burns/injuries

A
  • damage to tissue of the resp tract (usually resp mucosa) d/t inhalation of hot air or noxious chemicals
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10
Q

smoke & inhalation injury leads to (2)

A
  • redness
  • airway swelling
    = major predictor of mortality in burn injured patients
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11
Q

what is imp regarding smoke & inhalation injury

A
  • rapid assessment (d/t major predictor of mortality)
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12
Q

what are electrical burns

A
  • result of intense heat generated from an electric current
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13
Q

all pts with electrical burns should be considered at risk for ..

A
  • potential cervical spine injury (contact w electrical current can cause muscle contractions strong enough to cause fractures of long bone & vertebrae)
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14
Q

electrical burns put the pt at risk of (5)

A
  • dysrhytmias
  • cardiac arrest
  • severe metabolic acidosis
  • myoglobinuria –> ATN
  • vfib
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15
Q

what are examples of causes of electrical burns (3)

A
  • powerlines
  • lightning
  • faulty electrical in houses
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16
Q

what is an example of a cold thermal injury

A
  • frostbite
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17
Q

treatment of burns is related to

A
  • severity of injury
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18
Q

severity of injury d/t burns is related to (4)

A
  • depth of burn
  • extent of burn calculated in percentage of total body surface area
  • location of burn
  • pt risk factors
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19
Q

what is a superficial burn

A
  • 1st degree

- burn that causes damage to the epidermis

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20
Q

describe the clinical appearance of a superficial burn (7)

A
  • erythema
  • blanching w pressure
  • pain
  • no or mild swelling
  • no vesicles or blisters
  • dry
  • hot
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21
Q

describe the impact of a superficial burn on tactile and pain sensation

A
  • still intact
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22
Q

what are 2 examples of causes of superficial burns

A
  • superficial sun burn

- quick heat flash

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23
Q

what is a deep partial thickness burn

A
  • 2nd degree

- involves the epidermis and dermis to varying depths

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24
Q

describe the clinical appearance of a partial thickness burn (6)

A
  • shiny
  • wet
  • fluid-filled vesicles
  • severe pain
  • mild to mod edema
  • shades of pink, red, white
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25
Q

what are possible causes of deep partial thickness burns (6)

A
  • flame
  • contact burns
  • chemical burns
  • scalding
  • tar
  • electrical current
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26
Q

what is a full thickness burn

A
  • 3rd & 4th degree

- all skin layers and corresponding nerve endings are destroyed

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27
Q

describe clinical appearance of a full thickness burn (6)

A
  • dry
  • waxy white
  • leathery or hard skin
  • insensitivity to pain
  • possible involvement of muscles, tendons, and bone
  • coagulation necrosis
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28
Q

what are some examples of causes of a full thickness burn (5)

A
  • flame
  • scalding
  • chemical
  • tar
  • electric current
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29
Q

what is required for healing w a full thickness burn

A
  • surgical intervention
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30
Q

skin reproducing (re-epithelializing) cells are located where? what implication does this have

A
  • throughout the dermis & along shafts of hair follicles & sebaceous glands
    = if signif damage to dermis, not enough skin cells remain to regenerate new skin = permanent, alternative source of skin needed
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31
Q

what may be required for treatment of a partial thickness burn

A
  • skin grafting
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32
Q

what are 2 commonly used guides for determing the extent of a burn wound

A
  1. rule of nines chart

2. lund-browder chart

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33
Q

which of the 2 guides for determining extent of burn injury is more accurate and why

A
  • lund-browder chart

- takes into consideration pts age, relative body-area size

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34
Q

describe the impacts of burns to the face, neck, and circumferential burns to the chest or back

A
  • can result in mechanical obstruction d/t edema, compartment syndrome, or leathery, devitalized tissue (eschar)
    = may inhibit resp function
  • include possible inhalation injury & resp mucosal damage
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35
Q

describe the impacts of burns to the face, neck, and circumferential burns to the chest or back

A
  • can result in mechanical obstruction d/t edema, compartment syndrome, or leathery, devitalized tissue (eschar)
    = may inhibit resp function
  • include possible inhalation injury & resp mucosal damage
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36
Q

what is imp with burns to the face, neck, and chest (2)

A
  • frequent resp assement

- anticipate potential airway complications

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37
Q

describe the impacts of burns to the hands, feet, joints, and eyes (4)

A
  • limit self care & functional abilities
  • can impact employment, social options
  • require significant adaptation to regular life
  • hands & feet challenging d/t superficial vascular & nerve systems & need to maintain their function during healing
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38
Q

what is imp w burns of the hands, feet, joints, and eyes

A
  • emotional supports
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39
Q

describe the impact of burns to the ears and nose

A
  • v susceptible to infection d/t poor blood supply to the cartilage
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40
Q

describe the impact of burns to the buttocks and perineum

A
  • highly susceptible to infection d/t potential to be soiled by bodily fluids
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41
Q

describe the impact of circumferential burns to the extremities (2)

A
  • can cause circulatory compromise distal to the burn (d/t edema, inelasticity of eschar = compartment syndrome)
  • can cause neuro impairement to affected extremitity
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42
Q

describe the impact of circumferential burns to the chest (2)

A
  • impact movement of chest wall

- r/o inhalation

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43
Q

what are risk factors that impact recovery from burns (4)

A
  • age
  • medical history
  • lifestyle
  • other injuries
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44
Q

describe the impact on age on healing from a burn injury (2)

A
  • older adult heals more slowly and experiences more difficulty w rehab
  • v. young and v. old have higher risk of morbidity and mortality
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45
Q

describe the impact that med history has on healing from burn injury (2)

A
  • history of CVS, resp, or renal disease = poorer prognosis r/t high demands on body
  • DM and peripheral vasc disease = high risk of poor healing & gangrene (esp. w foot and leg burns)
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46
Q

describe the impact that lifestyle has on healing from burns (3)

A
  • alcoholism
  • drug abuse
  • malnutrition
    = less physiologicall able to recover from burn injury
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47
Q

describe the impact that other injuries have on healing from burns

A
  • factures
  • head injuries
  • and other trauma
    = poorer prognosis for recovery
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48
Q

what is an escharotomy

A
  • procedure performed by a surgeon
  • surgical incision through the eschar to release the constriction, thereby restoring distal circulation and allowing for adequate ventilation
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49
Q

when is an escharomty performed

A
  • within first 2-6 hr of burn injury
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50
Q

how does an escharomty differ from a fasciotomy

A
  • fasciotomy = incision to decomp tissue compartment
  • escharotomy does not breach deep fascia layer
  • same purpose, diff layer of tissue
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51
Q

what are S&S of inhalation injury (4)

A
  • initially = no symptoms
  • may see soot on face and around mouth
  • singed hair
  • over time: SOB, wheezing, hoarseness
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52
Q

what is imp to identify inhalation injury

A
  • resp assessment (RR, auscultate, O2 sats)
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53
Q

describe nursing care for a partial & full thickness burn to the face (2)

A

(high potential for resp complications d/t edema)

  • likely high rates of O2 (10L)
  • up in high fowlers (unless spinal contraindications)
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54
Q

why is it imp that a pt with a partial & full thickness burn to the face is in high fowlers position

A
  • encourages optimal lung expansion and airway opening
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55
Q

describe the impact of facial burns involving the lips & mouth (4)

A
  • causes swallowing difficulty
  • severe edema d/t patho response & aggressive fluid replacement
  • may be hoarse
  • stridor, wheezing
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56
Q

what might be indicated w facial burns involving the lips & mouth

A
  • intubation thru nares (uncommon, but may not be able to intubate thru mouth d/t signif edema)
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57
Q

what are the 3 phases of burn management

A
  • emergent (resuscitative, hypovolemic)
  • acute (wound healing, diuresis)
  • rehab (restorative)
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58
Q

describe the care in the phases of burn mngmt

A
  • the care overlaps from one stage to another
    ex. emergent phase is seen as beginning in the ED, care often beging at the scene
    ex. planning for rehab begins on the day of the burn injury or admission to burn unit
    ex. wound care is primary focus in acute phase, but also takes place in the emergent and rehab phase
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59
Q

describe what is included in prehospital care for burn injuries (5)

A
  • priority = remove from source of burn & stop burn process
  • if small, cooling of injured area thru use of clean, cool, tap water-dampened towel
  • if large (>10% TBSA), focus on ABCs
  • remove as much burned clothing as possible
  • wrap pt on dry, clean sheet or blanket for warmth and pevent contamination
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60
Q

what is included in assessment of airway for burn injuries (4)

A
  • check for patency
  • assess for soot around nares, on tongue
  • assess for singed nasal hair
  • assess for darkened oral or nasal membranes
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61
Q

what is included in assessment of breathing for burn injuries

A
  • check for adequacy of ventilation
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62
Q

what is included in assessment of circulation for burn injuries (2)

A
  • check for presence and regularity of pulses

- elevate burned limb above lvl of heart to decrease pain & swelling

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63
Q

to prevent hypothermia, large burns should be cooled for no more than?

A
  • 10 min
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64
Q

what are imp considerations when cooling off a burn injury (2)

A
  • do not immerse in cool water

- do not cover w ice

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65
Q

what is the emergent phase of burn mngmt

A
  • the period of time required to resolve the immediate, life threatening problems resulting from the injury
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66
Q

how long does the emergent phase last

A
  • up to 72 hrs from time of the burn (textbook)

- first 24-48 hrs (study guide posted on UM Learn)

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67
Q

what are the primary concerns during the emergent phase of burn mngmt (2)

A
  • onset of hypovolemic shock

- formation of edema –> airway

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68
Q

at what point does the emergent phase end

A
  • w fluid mobilization and diuresis
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69
Q

what 2 events occur during the emergent phase

A
  • increased capillary permeability = massive fluid shifts = fluid out of blood vessels into interstitial spaces = edema & hypovolemia
  • immmunological changes = risk of infection
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70
Q

the greatest initial threat to a pt with a major burn is ____. why?

A
  • hypovolemic shock
  • d/t massive shift of fluids, Na, and plasma proteins (albumin) out of blood vessels into intersitital spaces and surround tissues (3rd spacing) d/t increased capillary permeability
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71
Q

what are hallmark signs seen during the emergent phase of burn mngnmt (9)

A
  • low urine output w high specific gravity (concentrated)
  • weight gain
  • edema
  • positive fluid balance (fluid gain greater than fluid loss)
  • low BP
  • tachycardia
  • pain (superficial to partial thickness)
  • blisters filled w fluid & protein (partial)
  • adynamic ileus (absent or decreased BS d/t trauma)
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72
Q

what fluid & electrolyte changes occur during the emergent phase of burn mgnmt (5)

A
  • hypovolemia
  • hyponatremia (shifts into interstitial space)
  • hyperkalemia (injured cells and hemolyzed RBCs release K)
  • hypoproteinemia
  • high hematocrit (d/t hemoconcentration d/t fluid loss)
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73
Q

what complications can occur during the emergent phase of burn injuries(6)

A
  1. hypovolemic shock
  2. airway distress
  3. impaired circulation
  4. acute renal failure
  5. dysrhytmias
  6. adynamic ileus
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74
Q

impaired circulation during the emergent phase can lead to (4)

A
  • ischemia
  • parasthesias
  • necrosis
  • gangrene
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75
Q

what can be done to restore circulation to the extremities

A
  • escharotomy
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76
Q

what can be done to restore circulation to the extremities

A
  • escharotomy
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77
Q

how can burns cause airway distress (4)

A
  • upper airway burns = edema and obstruction of airway
  • burns to neck and chest = inelastic eschar = resp difficulty
  • inhalation of fumes or smoke = interstitial edema = prevents diffusion of O2 from the alveoli into the circulatory system
  • risk of pneumonia
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78
Q

how can burns cause acute renal failure & ATN (2)

A
  • hypovolemia = decreased blood flow to kidneys = renal ischemia
  • release of myoglobin and hemoglobin with full thickness and electrical burns = occlude renal tubules
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79
Q

how can burns can adynamic ileus (3)

A
  • d/t shunting and decreased perfusion
  • response to massive trauma
  • potassium shifts
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80
Q

pre-existing heart disease or lung disease can causes what complication during the emergent phase of burn mngmt

A
  • heart failure or pulmonary edema (d/t fluid replacement)
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81
Q

what are the priority nursing diagnoses during the emergent phase of burn mngmt (6)

A
  • ineffective airway clearance
  • fluid volume deficit d/t cap leak
  • impaired tissue perfusion
  • altered comfort, pain, and anxiety
  • risk for infection
  • altered nutrition
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82
Q

what is included in collab care during the emergency phase (13)

A
  • ABCs
  • airway mngmt
  • fluid therapy
  • wound care
  • drug therapy
  • nutritional therapy
  • remove clothing so doesnt stick to burned skin
  • eye exam for face burns
  • elevate burnt area
  • hourly urine outputs
  • monitor fluid & E
  • physio –> ROM
  • emotional support
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83
Q

why is early endotracheal intubation imp during the emergent phase

A
  • once edema sets in might not be possible

- eliminates the necessity for emergency tracheostomy after resp problems become apparent

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84
Q

what is included in airway mngmt during the emergent phase (13)

A
  • resp & chest assessment
  • early endotracheal (preferably orotracheal)–> within 1-2 hrs after injury
  • ventilatory assistance
  • ABGs –> determine O2 conc
  • escharomoties of chest wall (if resp distress d/t circumferential, full thickness burns of neck and trunk)
  • chest xray
  • bronchoscopy
  • high fowler’s
  • DB&C
  • turn q1-2 h
  • chest physio
  • suctioning as needed
  • bronchodilators
  • positive end expiratory pressure
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85
Q

when intubation is performed, treatment of inhalation injury includes?

A
  • admin of 100% humidified O2 as needed
86
Q

at what point does extubation occur

A
  • once edema resolves, usucally 3-6 days after burn injury

* unless severe inhalation injury is involved*

87
Q

why is a bronchoscopy performed during the emergent phase? when should it be done?

A
  • assess lower airway
  • look for deeper injury
  • complete within first 6-12 hrs when smoke inhalation is suspected or known
88
Q

how is CO poisoning treated

A
  • 100% O2 until resolved
89
Q

what is included in fluid therapy during the emergent phase (4)

A
  • establish IV access –> 2 large bore routes
  • crystalloid solutions (LR)
  • colloids (albumin)
  • insert foley cath
90
Q

why is establishing IV access critical during the emergent phase (2)

A
  • fluid resus

- drug admin

91
Q

what does the C stand for in ABCs for burn mngmt

A
  • fluid resus
92
Q

why is fluid replacement imp during the emergency phase (2)

A
  • support BP

- prevent hypovolemic shock

93
Q

what is used to estimate fluid replacement

A
  • the parkland (Baxter) formula –> based on pt’s body weight and TBSA burned
94
Q

what clinical parameteres indicate the adequacy of fluid replacement (4)

A
  • urine output of 30-50 mL/hr (at least)
  • systolic BP greater than 90
  • HR less than 120
  • peripheral pulses (indicate if adequate circulation or not)
95
Q

what is done if the clinical parameters for fluid replacement are not met?

A
  • increase rate of fluid resus
96
Q

once a patent airway, adequate circulation, and adequate fluid replacement have been established, what is the next priority of care

A
  • the burn wound
97
Q

what is included in wound care during the emergent phase (3)

A
  • cleansing
  • gentle debridement
  • prevent infection & cross contamination
98
Q

what is debridement

A
  • removal of necrotic skin
99
Q

what is included in drug therapy during the emergency phase (6)

A
  • analgesics
  • sedatives
  • tetanus immunization
  • antimicrobial, topical agents to the wound
  • systemic anitbiotcs if sepsis or other infection (ex. pneumonia)
  • venous thromboembolism prophylaxis
100
Q

what is an examples of antimicrobial agents applied to the wound

A
  • silver impregnanted dressings
101
Q

why arent systemic antibiotics typically used to control wound bed flora

A
  • d/t lack of blood supply to eschar = minimal delivery of ab to wound
102
Q

why is early & agressive nutritional support within several hours of the burn injury imp (3)

A
  • decrease mortality risks & complications
  • optimize healing
  • minimize negative effects of hypermetabolism and catabolism
103
Q

describe nutritional therapy during the emergent phase (4)

A
  • high protein
  • high cal
  • supplmental vitamins
  • if paralytic ileus –> NG tube
104
Q

what 2 priority nursing diagnoses during the emergent phase carry over to the acute phase

A
  • high risk for infection

- altered nutrition

105
Q

when does the acute phase of burn mngmt begin? when does it end?

A
  • when mobilization of extracellular fluids beging & subsequent diuresis
  • ends when the burned area is completed covered by skin grafts or when the wounds are healed
106
Q

how long does the acute phase last

A
  • begins after 48-72 hrs post-burn

- continues for weeks to months

107
Q

what pathophysiological events occur during the acute phase of burn injuries (4)

A
  • pt more stable, ABCs managed
  • fluid mobilizes –> capillary leak sealed & fluid shifts back to vascular space & diuresis occurs = less edema
  • hypermetabolism
  • BS return
108
Q

what hallmark signs are present during the acute phase of burn injuries (7)

A
  • high urine output (200-300 mL/hr)
  • diluted urine, diuresis
  • decreased edema
  • decreased weight
  • wounds are boggy , sloughing occurs
  • bounding pulses
  • BP increase (d/t fluid shift back to vascular space)
109
Q

what fluid & electrolyte changes are present during the acute phase of burn injuries (6)

A
  • hypervolemia
  • hyponatremia (d/t diuresis)
  • hypokalemia (d/t diuresis)
  • BUN and creatinine increased
  • hemodilution
  • hypoproteinemia
110
Q

what complications may occur during the acute phase of burn mngmt (9)

A
  • fluid overload
  • curling’s ulcer
  • CHF & pulm edema
  • infection
  • neuro changes
  • musculoskeletal changes
  • GI changes
  • stress diabetes
  • psychosis / emotional changes
111
Q

what is often the source of infection in burn wounds

A
  • the pt’s own flora –> from the skin, resp tract, GI tract
112
Q

what types of infection can occur during the acute phase of burn mngmt (2)

A
  • burn wound infection

- sepsis

113
Q

what can cause neuro changes in the acute phase of burn mngmt

A
  • severe hypoxia from resp injuries or complications
114
Q

what musculoskeletal changes can occur during the acute phase of burn mngmt and why

A
  • burns begin to heal & scar tissue forms = skin less supple & pliant
  • r/o ROM limited & contractures
  • r/o pressure sores and skin breakdown
115
Q

how can limited ROM and contractures be avoided during the acute phase of burn mngmt (4)

A
  • encourage pt to stretch and move burned body parts as much as possible
  • splinting
  • reposition
  • use of pressure deviced
116
Q

what GI complications can occur during the acute phase of burn mngmt (4)

A
  • constipation d/t opioids, decreased mobility, low fibre diet
  • curling’s ulcer
  • diarrhea from enteral feedings & antibiotics
  • paralytic ileus from sepsis
117
Q

what is curling’s ulcer

A
  • type of gastroduodenal ulcer

- acute gastric erosion characterized by diffuse, superficial lesions (including mucosal erosion)

118
Q

what causes a curling’s ulcer

A
  • stress response to decreased blood flow to the GI tract during the emergent phase = decreased mucous, increased gastric acid, ischemia & cell necrosis
119
Q

what is the prevention for curling’s ulcer (4)

A
  • feed patient ASAP after injury
  • antacids
  • H2RB
  • PPIs
120
Q

how can burn injuries cause stress diabetes (2)

A
  • d/t stress-mediated cortisol and catecholamine release

- increased caloric intake to meet metabolic needs

121
Q

what are the priority nursing diagnosis during the acute phase of burn mngmt (8)

A
  • fluid volume excess
  • comfort/pain
  • high risk of infection
  • altered nutrition
  • ineffective sleep pattern
  • ineffective coping
  • self-care deficit
  • disturbance in self-concept and self-image
122
Q

what is included in collab care during the acute phase (6)

A
  • wound care
  • excision and grafting
  • pain mngmt
  • physical and occupational therapy
  • nutritonal therapy
  • psychosocial care
  • monitor I&O
  • expect multiple surgeries for grafting & debridement
123
Q

what are the goals of wound care for burn injuries (3)

A
  • prevent infection
  • promote wound re-epithelialization thru grafting
  • promote healing
124
Q

why is debridement imp (2)

A
  • enhances healing

- removes necrotic tissue that would promote bacterial growth = reduce risk of infection & sepsis

125
Q

what does wound care of burn injuries include (8)

A
  • observation
  • assessment
  • cleansing
  • debridement
  • dressing changes
  • topical microbial therapy
  • graft care
  • donor site care
126
Q

where can cleansing and gentle debridement w scissors or forceps be done (3)

A
  • in cart shower
  • regular shower
  • pts bed or stretcher
127
Q

when open burn wounds are exposed, what PPE must be worn (4)

A
  • gown
  • mask
  • gloves
  • hair cover
128
Q

what is the nurses role for wound care r/t burn injuries (7)

A
  • read physicians orders re wound care
  • manage pain
  • know types of dressings
  • assess if graft is taking
  • documentation v imp for trajectory of healing process
  • aseptic technique
  • prevent cross contamination between pts
129
Q

describe how dressings for burn injuries should be

A
  • should be saturated
130
Q

when are complete wound assessments completed

A
  • on takedown day
131
Q

how long can dressings be place between takedown day? why is this imp?

A
  • 5-7 days

- cooling the wound bed delays healing & may disrupt potential graft sites, r/o infection the more it is exposed

132
Q

what is hydrotherapy

A
  • uses warm running water to gently cleanse and help the healing process of a burn injury
  • usually performed on shower table
133
Q

what is 2 approaches to burn wound treatment

A
  • open method

- multiple dressing change/closed

134
Q

what is the open method for burn wound treatmenr

A
  • pts burn is covered w a topical antimicrobial and has no dressing over the wound
  • involves cleansing followed by burn cream
135
Q

on what body parts is the open method often used (2)

A
  • facial burns

- ears

136
Q

what is the multiple dressing change or closed method for burn wound treatment

A
  • involves use of sterile gauze dressings impregnated w or laid over a topical antimicrobial
137
Q

what are burn wounds cleansed w

A
  • soap & water

- or NS moistened gauze

138
Q

after a burn has been debrided, what is next completed

A
  • topical microbial cream applied
  • a protective coarse or fine-meshed, grease based (ex. petroleum) gauze dressing applied to protect the re-epithelializing cells and close the wound bed
139
Q

what is an example of a microbial burn cream

A
  • flamazine –> silver sulfadiazine cream
140
Q

how many people are required for takedown day? why?

A
  • multiple person operation
    1. want to minimize movement to prevent pain = one to support limbs
    2. be quick d/t pain, exhuasting, and don’t want wounds open too long
141
Q

what is a non-adherent dressing used for burn wounds

A
  • adaptic –> impregnanted w petroleum
142
Q

if grafting is required, describe the dressing used (2)

A
  • the meshed, split thickness skin graft protected w grease based dressing (ex. petroleum)
  • followed by middle & outer dressing
143
Q

describe a risk associated w facial grafts

A
  • the unmeshed sheet graft is left open = risk of formation of blebs
144
Q

what are blebs

A
  • serosanguinous exudates that form between the graft and recipient bed
145
Q

what is the consequence of the formation of blebs

A
  • prevent the graft from permanently attaching to the wound
146
Q

what is that treatment for a bleb

A
  • aspiration w a TB syringe by a surgeon or specially trained nurse
147
Q

what is excision and grafting

A
  • procedure that involves excision (removal) of devitalized (eschar) tissue down to the subcut tissue or fascia, depending on injury depth
  • followed by later coverage w a graft
148
Q

excision and grafting is best practice for what type of burns

A
  • full thickness
149
Q

what is a good sign after debridement of a burn wound

A
  • if the wound looks bloody = good blood supply = should take skin graft well
150
Q

when is skin grafting required

A
  • when layers of skin responsible for regeneration is destroyed (full thickness, sometimes partial)
151
Q

what is the goal of skin grafting

A
  • cover the burned areas to promote healing and prevent infection & sepsis
152
Q

excision & grafting is done under..

A
  • general anasthesia
153
Q

what is an imp nursing consideration w skin grafting? why is this imp

A
  • freq assessment for bleeding & circulation problems

- clots and other complications could impact graft’s ability to adhere & take

154
Q

graft tissue is removed from donor sites using? how does it work

A
  • a dermatone –> removes thin split-thickness layer of skin to be used on burn site
155
Q

what is required w skin grafting

A
  • care of both the graft site (burn wound) and the donor site
156
Q

how can grafts be kept in place (3)

A
  • fibrin sealant
  • staples
  • sutures
157
Q

what is an autograft (3)

A
  • harvest of the pt’s own skin for graft
  • gold standard for grafting but may not be possible based on TBSA burned
  • permanent graft
158
Q

what is a allograft or hemograft

A
  • temporary graft obtained from another human being that is used to test the auitability of the recipient site to accept a graft
159
Q

how long can allografts stay in place for

A
  • 3 days - 2 weeks
160
Q

autografts can be either…

A
  • meshed –> ratio of 1.5:1 for better wound coverage

- unmeshed –> better cosmetic result (face, neck, hands)

161
Q

what are the goals of donor site care (3)

A
  • rapid, moist wound healing
  • decrease pain
  • prevent infection
162
Q

what is Cultured Epithelial Autograft (CEA)

A
  • method of obtaining permanent skin from a person w limited available skin for harvesting (large body SA burns)
  • grown from biopsy specimens obtained from pts own unburned skin
  • the cultured skin is then placed on the pts excised burn wounds
163
Q

what are some cons associated w CEA (2)

A
  • takes long time

- delicate

164
Q

what is a heterograft or xenograft

A
  • temporary graft from a different species

ex. pig

165
Q

what is biobrane

A
  • temporary use of artificial skin for use in treatment of full thickeness or partial burns when autograft is not available
166
Q

what may occur during excision of a burn wound?

A
  • risk of massive blood loss & clot formation –> monitor!
167
Q

what is included in nursing care of grafts (4)

A
  • initial dressing = security and compression
  • dressing splinted if across a joint
  • protect graft from shearing, pressure, movement, injury
  • wound care imp
168
Q

what is done on “takedown day” (5)

A
  • surgeon examines site
  • % adhered –> progress of healing
  • remove every 2nd staple
  • pictures taken
  • culture in indicated
169
Q

why is every 2nd staple removed at first on takedown day

A
  • to see how its healing and if the graft is taking before removing all staples
170
Q

the frequency of dressing changes for burn wounds can be anywhere between

A
  • 3-14 days
171
Q

what is a free graft

A
  • involves moving a piece of donor skin from 1 place to another, while it does not maintain its original blood supply –> takes on new blood supply
172
Q

for a fullthickness free graft, how is the donor site closed? partial/split thickness?

A
  • full = surgically closed
  • partial = meshed or unmeshed sheet –> donor site requires regular dressing changes

??idrk what this means

173
Q

what is a skin flap

A
  • involves skin & subcut tissue that maintain their original blood supply & vascular attachment = pedicle
174
Q

describe pain experienced by pts during the acute phase

A
  • experience a continuous background pain present thru day & night
  • and treatment induced pain associated w dressing changes and rehab activites
175
Q

describe pain mngmt during the acute phase (4)

A
  • continuous IV infusion of opioid for background pain
  • for treatment induced: premedicate, low doses during treatment,
  • rigorous pain assessment & re-evaluation imp d/t risk of tolerance and breakthrough pain
  • may involve combo of opioids and sedatives (ex. benzos)
176
Q

why is PT imp during the acute phase of burn mngmt (3)

A
  • maintain muscle strength
  • maintain joint function
  • prevent contractures
177
Q

describe PT during the acute phase (4)

A
  • complete passive and active ROM
  • often done during and after dressing changes
  • use of splints to keep joints in functional position
  • do not bend affected limb
178
Q

why is nutritonal therapy imp during the acute phase of burn mngmt

A
  • pt in hypermetabolic state & need to promote wound healing
179
Q

what is included in nutritonal therapy during the acute phase (7)

A
  • high cal
  • high protein
  • high carb
  • if on mechanical ventilator or NPO, use of feeding tube indicated
  • swallowing assessment & BS before oral feeding
  • pt’s appetite may be diminished
180
Q

describe psychosocial care during the acute phase (3)

A
  • encourage friends & family support
  • recommend community resources
  • referral for social work if needed
181
Q

what peds considerations should be considered during the acute phase of burn mngmt

A
  • debridement and dressing changes often done in OR under sedation –> v painful and traumatic , lack coping mechanisms
  • avoid additional stress
182
Q

what can help increase pts comfort and conserve energy during the acute phase of burn mngmt (4)

A

decrease catecholamine release by minimizing:

  • pain
  • anxiety
  • fear
  • cold
183
Q

what is the rehabilitation phase of burn mgnmt

A
  • phase that begins when the pts burn wounds have healed and the pt is able to resume a lvl of self-care activity
184
Q

when does the rehab phase begin? end?

A
  • begins in acute phase

- continues for months/years

185
Q

what are the goals for the rehab period (2)

A
  • assist pt in resuming a functional role in society

- rehab after functional and cosmetic reconstructive surgery

186
Q

what pathophysiological events occur during the rehab phase (4)

A
  • collagen fibres present in new scar tissue to assist w healing & add strength
  • hypertrophic scarring
  • if adequate ROM is not maintained, contractures occur
  • mature healing in ~12 months
187
Q

burn wound scarring has 2 components. what are they

A
  1. discoloration

2. contour

188
Q

describe discoloration r/t burn wounds

A
  • at first is pink or red

- eventually discoloration of scars fades somewhat w time

189
Q

describe contour r/t burn wound scarring

A
  • develops altered contours where it is no longer flat or sightly raised, but becomes elevated and enlarged above the original burn injury area
190
Q

what can help keep burn scars flat (prevent hypertrophic scarring)

A

compression:

- use of custom fitted pressure garments ex. jobst garments

191
Q

what are imp considerations/pt teaching for pressure garments used in the rehab phase (4)

A
  • never be worn over unhealed wounds
  • removed only for short periods of time while bathing
  • worn up to 24h/day for as long as 12-18 months
  • water-based moisturizers or oral antihistmines for itching
192
Q

what is the hallmark sign of the rehab phase of burn injuries

A
  • decreased ROM
193
Q

what 2 complications can occur during the rehab phase

A
  • contractures

- hypertrophic scarring

194
Q

what is a contracture

A
  • an abnormal condition of a joint characterized by flexion and fixation that develops d/t shortening of scar tissue in the flexor tissues of a joint
195
Q

what areas are susceptible to contractures (8)

A
  • anterior and laterial neck areas
  • axillae
  • antecubital fossae
  • fingers
  • groin area
  • popliteal fossae
  • knees
  • ankles
196
Q

why is there a risk of contractures during the rehab phase (2)

A
  • pts prefer to assume a flexed position for comfort d/t pain
  • deceased movement
197
Q

what can help prevent contractures during the rehab phase (4)

A
  • positioning
  • compression garments
  • splinting
  • exercise –> ROM, ADLs, active rehab
198
Q

what are the priority nursing diagnoses during the rehab phase (5)

A
  • altered comfort d/t pain & itchiness
  • self care deficit
  • impaired physical mobility
  • disturbance of self concept & self image
  • anxiety
199
Q

what are the primary goals during the rehab phase (2)

A
  • continued wound care as required

- functional support

200
Q

what is included in pt teaching during the rehab phase (8)

A
  • teaching r/t pressure garments
  • no sun for 1 year –> keep covered, wear sunscreen
  • newly formed skin is v sensitive to trauma –> blisters and skin tears are likely to develop from slight pressure or friction
  • newly healed areas hypersensitive to cold, heat, and touch
  • education on wound care
  • strategies to decrease itching & flaking
  • may require future reconstructive surgery
  • exercise, PT, OT very imp for next 6-12 months
201
Q

what are some strategies to reduce itching and flaking during the rehab phase (2)

A
  • use an emollient water-based cream (ex. vaseline) that penetrates the dermins to keep skin supple & moisturized
  • oral antihistamines
202
Q

what is included in collab care during the rehab phase (4)

A
  • education
  • emotional support
  • continued wound care as required
  • PT and OT v imp
203
Q

describe diet during the rehab phase

A
  • normal diet as tolerated
204
Q

a nursing diagnosis for burns is deficient fluid volume. what are some nursing interventions for this during the emergent phase (^)

A
  • monitor hemodynamic status
  • keep an accurate I&O
  • obtain lab specimens as appropriate (hematocrit, Na, K, BUN)
  • admin IV electrolyte solution
  • monitor for signs of electrolyte and fluid imbalance
  • daily weights
205
Q

a nursing diagnosis r/t burn injuries is acute pain. what are some nursing interventions for this during the emergent phase (7)

A
  • use pain control measures before pain becomes severe
  • provide optimal pain relief w opioids
  • ensure pretreatment analgesia
  • offer nonpharmacological interventions
  • evaluate effective of pain control measures
  • observe for nonverbal cues of pain
  • institute and modify pain control measures on the basis of the pt’s response
206
Q

a nursing diagnosis r/t burn injuries is acute pain. what are some nursing interventions for this during the acute phase (6)

A
  • reduce or eliminate factors that cause or increase pain
  • promote adequate rest or sleep
  • teach use of nonpharmacological technqiues
  • medicate prior to activities
  • encourage pt to monitor his or her own pain and intervene approp
  • monitor pt satisfaction w pain mngmt at intervals
207
Q

a nursing diagnosis r/t burn injuries is acute pain. what are some unrsing interventions for this during the rehab phase (2)

A
  • determine impact of pain on WOL

- assist pt and damily to seek and obtain support for residual pain

208
Q

a nursing diagnosis r/t burn injuries is impaired tissue integrity. what are some nursing interventions for this in all phases (10)

A
  • monitor for S&S of infection
  • administer immunizing agent (tetanus)
  • obtain cultures
  • promote sufficient nutritional intake
  • use appropr PPE during wound care
  • shave hair usrrounding the affected area to reduce contamination
  • monitor wound for S&S of infection
  • clean w NS or soap & water
  • apply approp burn cream , dressing , or both
  • maintain sterile technique
209
Q

a nursing diagnosis r/t burn injuries is imbalanced nutrition : less than body requirements. what are some nursing interventions for this during the emergent phase

A
  • determine in collab w dietician # of cals and nutrients needed
  • admin parental fluids
  • initiate enteral feedings asap until oral intake can be resumed
  • d/s use of enteral feedings as oral intake is tolerate
  • monitor food and fluids ingested
210
Q

a nursing diagnosis r/t burn injuries is imbalanced nutrition: less than body requirements. what are some nursing intervetions for this during the acute phase (5)

A
  • provide pt w high cal, high protein, nutritious foods
  • select nutritional supplements as needed
  • determine food preferences
  • monitor food & fluid ingested
  • monitor weight

NURS 3512 - Class 7-12 (49 decks)

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