Ch 25 - Burns - Nursing/Collaborative - Emergent Phase

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Emergent Phase - survival depends on

rapid & thorough assessment & interventions

Emergent Phase - assess

depth & extent of burn
possible transfer to burn center

Emergent Phase - primary collaborative management

airway
fluid
wound care

Emergent Phase - initial positioning

proper positioning
splinting

Emergent Phase - airway management

early endotracheal (preferable orotracheal) intubation

Emergent Phase - early endotracheal why

eliminates need for emergency trach after repiratory problems become apparent

Emergent Phase - burns to face & neck - intubation when

within 1-2 hours after burn injury

Emergent Phase - after intubation

ventilatory assistance

Emergent Phase - oxygen amount delivered

determined by ABGs

Emergent Phase - extubation when

when edema resolves
usually 3-6 days after injury
unless severe inhalation injury

Emergent Phase - escharotomies of chest

to relieve respiratory distress secondary to circumferential, full-thickness burns of neck & trunk

after smoke inhalation - what test

fiberoptic bronchoscopy

fiberoptic bronchoscopy when/why

within 6-12 hours after injury w/smoke inhalation
assess the lower airway

fiberoptic bronchoscopy - significant findings

appearance of carbonaceous material
mucosal edema
vesicles
erythem
hemorrhage
ulceration

smoke inhalation - O2 requirements w/o intubation

100% humidified O2

Emergent Phase - positioning

high Fowler's unless contraindicated (spinal injury)

Emergent Phase - encourage for respiratory

coughing & deep breathing every hour
PT
suctioning

Emergent Phase - if respiratory failure

intubation
mechanical ventilation
positive end-expiratory pressure to prevent collapse of aveoli & progressive respiratory failure

Emergent Phase - for severe bronchospasm

bronchodilators

Emergent Phase - CO poisoning treatment

100% O2
until carboxyhemoglobin levels return to normal
hyperbaric O2 therapy remains controversial

Emergent Phase - Fluid - IV managment

establish IV access for fluids/meds
two large bore IV access routes w/burn >15% TBSA
IV access for large volumes of fluid

Emergent Phase - Fluid Therapy - Burns >30% TBSA

central line for fluid & meds
blood sampling
arterial line may also be considered if frequent ABGs or invasive BP monitoring needed

Emergent Phase - Fluid Therapy - Needs

based on chart
allows for accuraate estimation of fluid resuscitation needs

Emergent Phase - Fluid Therapy - fluid replacement determined by

size & depth of burn
age
individual considerations
preexisting illness

Emergent Phase - Fluid Therapy - solutions used

crystalloid solutions - usually lactated Ringer's
colloids - albumin
or combination of two
paramedics usually give IV saline until arrival at hospital

Emergent Phase - Fluid Therapy - Parkland (Baxter) formula for fluids replacement

most common
used followed by the modified Brooke formula

Emergent Phase - Fluid Therapy - important to remember

all formulas are estimates
must be titrated
example: patients w/electrical energy may need more fluids

Emergent Phase - Fluid Therapy - colloidal solutions example

albumin

Emergent Phase - Fluid Therapy - colloidal solutions when given

after first 12 - 24 hours postburn
when capillary permeability returns to normal or near normal

Emergent Phase - Fluid Therapy - colloidal solutions timing why

plasma remains in vascular space & expands circulating volume

Emergent Phase - Fluid Therapy - fluid replacement calculations

based on patient's body weight and TBSA burned

Emergent Phase - Fluid Therapy - calculations example

0.3 to 0.5 mL/kg/%TBSA burn

Emergent Phase - Fluid Therapy - assessment - clinical parameters

urine output - most common

Emergent Phase - Fluid Therapy - cardiac parameters - urine output

0.5 to 1 mL/kg/hr
75 to 100 mL/hr for electrical burn patient w/evidence of hemoglobinuria/myoglobinuria

Emergent Phase - Fluid Therapy - cardiac factors

MAP >65 mmHg
systolic BP >90 mmHg
HR<120 bpm

Emergent Phase - Fluid Therapy - MAP and BP measurements

arterial line

Emergent Phase - Fluid Therapy - peripheral measurement

often invalid due to vasoconstriction & edema

Emergent Phase - Wound Care - after when

patent airway
adequate fluids replaced

partial-thickness wounds - appearance

pink to cherry-red
wet & shiny
serous exudate
may or may not have intact blisters
painful when touched & exposed to air

full-thickness burns - appearance

dry & waxy
white to dark brown/black
only minor, localized sensation due to nerve endings being destoyed

Emergent Phase - Wound Care - interventions

cleansing & gentle debridement using scissors & forceps can occur in cart shower, regular shower, or patient bed/stretcher

Emergent Phase - Wound Care - operating room

extensive, surgical debridement
releasing escharotomies & fasciotomies can be done

Emergent Phase - Wound Care - debridement

necrotic skin removed

Emergent Phase - Wound Care - effects on person

physically & psychologically demanding
emotional support needed

Emergent Phase - Wound Care - showering

tap water
not exceeding 104 F, 40 C
once-daily showering

Emergent Phase - Wound Care - dressing change

morning
evening
some newer antimicrobial dressing can be left in place from 3-14 days

Emergent Phase - Wound Care - most serious threat

infection
sepsis

Emergent Phase - Wound Care - sources of infection in burn wounds

patient's own flora, predominantly from skin (burned & unburned)
respiratory tract
Gastrointestinal tract

Emergent Phase - Wound Care - treatment approaches types

open method
multiple dressing or closed method

Emergent Phase - Wound Care - open method

burn is covered with a topical antimicrobial
no dressing over wound

Emergent Phase - Wound Care - multiple dressing (closed method)

sterile gauze dressing impregnated with or laid over a topical antimicrobial

Emergent Phase - Wound Care - multiple dressing (closed method) - dressings changed when

every 12-24 hours to once q 14 days
depends on product
most burn centers support moist wound healing & use dressing to cover burned areas, with exception of face

Emergent Phase - Wound Care - open wounds precautions

PPE
disposable hats, masks, gowns, gloves
nonsterile disposable gloves when removing contaminated dressing & washing dirty wound
sterile gloves when applying ointments & sterile dressings

Emergent Phase - Wound Care - room temperature

warm
85 F
30 C

Emergent Phase - Wound Care - aseptic

remove PPEs before treating next patient
hand washing & alcohol gel
after dressing change - equipment & environment cleaned & disinfected
use of plastic liners on equipment helpful

Emergent Phase - Wound Care - primary goal for burn wounds

coverage
rarely enough unburned skin in major (greater than 50% TBSA) burn patient for immediate skin grafting

Emergent Phase - Wound Care - methods when not enough skin for grafting

allograft (homograft)
usually from cadavers
used, along with newer biosynthetic options

Emergent Phase - other nursing care measures - areas that need extra attention and care

face
eyes
hands
arms
ears
perineum

Emergent Phase - other nursing care measures - face

highly vascular
subject to alot of edema
often covered with ointments & gauze
not wrapped to limit pressure on facial features

Emergent Phase - other nursing care measures - eyes -corneal burns or edema

antibiotic ointments
ophthalmology exam soon after admission when facial burns
periorbital edema can prevent opening of eyes - frightening
provide assurance swelling not permanent
instillation of methylcellulose drops or artifical tears for moisture/comfort

Emergent Phase - other nursing care measures - ears

kept free of pressure due to poor vascularization & predisposed to infection

Emergent Phase - other nursing care measures - ears - interventions

no pillows because pressure on cartilage may cause chondritis & ear may stick to pillow
causes pain & bleeding

Emergent Phase - other nursing care measures - ears/head placement

elevated using a rolled towel placed under shoulders
careful to avoid pressure necrosis
same for neck burns
pillows removed & rolled towel placed under shoulders to hyperextend neck & prevent neck wound contraction

Emergent Phase - other nursing care measures - hands & arms - position

extended & elevated on pillows
reduces edema
splints may be used to maintain in positions of function

Emergent Phase - other nursing care measures - perineum

kept clean & dry
provide hourly urine outputs
an indwelling cath prevents urine contamination of area
regular 1-2 X daily peri and cath care with or without perineal burn

Emergent Phase - other nursing care measures - lab tests

F&E
ABGs - to dermine ventilation & perfusion with inhalation or electrical injury

Emergent Phase - other nursing care measures - PT - when

immedately
during showering/dressing changes
before new dressings applied
ROM to faciliate mobilization of extravasated fluid back into vascular bed

Emergent Phase - other nursing care measures - PT - other benefits

maintains function
prevents contractures
reassures patient movement is possible

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