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What are the pathophysiologic changes after a burn?

Increased capillary permeability
Increased pulse
Fluid volume deficit
Decreased CO
Decreased UO
Epinephrine secretion for vasodilation
ADH secretion to increase blood volume
Aldosterone secretion to increase blood volume
Decreased blood pressure and then increased blood pressure

What chemicals are secreted during a burn?

Epinephrine secretion for vasodilation
ADH secretion to retain water and increase blood volume
Aldosterone secretion to retain sodium and water and increase blood volume

How can shock occur?

Heat damage causes increased capillary permeability leading extreme third spacing.

When does the pulse increase?

Any time you are in a fluid volume deficit, the pulse will increase.

Why does the blood pressure decrease then increase

Epinephrine causes vasodilation decreasing BP, then fight/fight hormones kick in causing vasoconstriction increasing the BP.

Why does the CO decrease

Fluid volume deficit, less volume, less output. Less volume to pump out.

Why does the urine output decrease?

Kidneys are not being perfused or they are trying to hold on to volume to compensate and not die.

Why is epinephrine secreted?

Causes vasodilation, shunts blood to vital organs, decreasing the BP.

Why are ADH and aldosterone secreted?

To hold on to water and sodium thus increasing blood volume

When does the majority of all of this occur?

1st 24 hours

How long does it take for kidneys to have permanent kidney damage.

20 minutes

What type of shock kills kidneys?

any type

What is the most common airway injury?

Carbon Monoxide poisoning

How does carbon monoxide cause hypoxia?

CO has a greater affinity for hemoglobin that O2. All of the hemoglobin binds with CO instead of O2 and cannot transport O2.

What do client's look like when they have CO poisoning?

Cherry red

Why is it important to determine if the burn took place in an enclosed space or not?

Closed space burns have more potential for airway injury.

What is the treatment for CO poisoning

100% oxygen with hyperbaric chamber

What may the doctor do prophylactically for airway burns?

Intubate or trach them (least invasive first) b/c airway will swell

What is the rule of nines?

Estimate of Total Body Surface Area that was burned
Genitalia = 1%
Left arm = 9%
Right arm = 9%
Left leg = 18%
Right leg = 18%
Head and Neck = 9 %
Front of Trunk = 18%
Back of Trunk = 18%

When is fluid replacement a concern?

greater than 20-25% TBSA

What is one of the most important aspects of burn management?

fluid replacement

Why is it important to determine the time that the burn occurred?

Fluid therapy for the first twenty four hours is based on the time the injury occurred, NOT when the treatment was started.

What is the Parkland formula?

Calculate what fluid is need for the first 24 hours and give HALF OF THE VOLUME CALUCATED DURING THE FIRST 8 HOURS.
2nd 8 hrs = 1/4 of the volume
3rd 8 hrs = 1/4 of the volume

(4mL of LR)(body weight in Kg)(TBSA burned) = total fluid requirement for the first 24 hours after the burn

What could restlessness indicate?

HYPOXIA
PAIN
INADEQUATE FLUID REPLACEMENT

What is the nurse's PRIORITY?

HYPOXIA

What would you choose to determine if a BURN pt's fluid volume is adequate.

URINE OUTPUT for burns

What can help stop the burning process

COOL water

No ice
Ice = too much vasoconstriction

Why remove jewelry?

swelling and metal gets hot

Do you remove the clothing

Yes, all non adherent but not melted.
Cover with a clean dry cloth.

Why is a burn patient at risk for hypothermia?

Loss of skin = loss of heat retaining mechanism.

What are some signs of airway injury?

singed facial/nasal hair
soot on their face
coughing black or black speckled sputum
blisters on oropharyngeal mucosa

If a client's respirations are shallow what can you assume?

poor gas exchange
they are retaining CO2 and in respiratory acidosis

What is the medication management for burns?

Albumin
Pain management
Immunizations

Why is albumin given?

Albumin increases vascular volume b/c it holds fluid in the vascular space.

What are the effects of albumin?

Increased BV
Increased kidney perfusion
Increased BP
Increased CO
Increased WORKLOAD ON THE HEART

What is a major risk when giving a person albumin?

Workload on the heart increases causing stress on the heart. If the heart is stressed too much, the pt will go into FLUID VOLUME EXCESS. The CO will decreased b/c the heart is failing and the lungs will sound WET.

When a client is rapidly receiving fluids, what HOURLY measurement can be made to ensure that you are not overloading the heart?

CVP
sudden jump in CVP means the right atria is filling very fast.

What is the most important assessment when administering narcotics for pain?

Respiratory

Why are IV pain meds preferred over IM in burn patients.

Act fast
For IM to work, muscles must be perfused

What kind of wound is a burn considered to be?

contaminated

What type of immunization should a burn patient get?

Tetanus

What type of immunity is the tetanus toxoid?

ACTIVE IMMUNITY

Explain active immunity,

Body takes an active role in production of antibodies.
Takes TIME to develop.
About 2-4 weeks to develop their own immunity.

What type of immunity is immune globulin?

PASSIVE IMMUNITY

Explain passive immunity?

IMEDIATE protection
Antibody injection
lasts about three months
Body just sits back and passively accepts the antibodies

what are the complications of burns?

pressure and poor perfusion to tissues
kidney failure
red/brown urine
hyperkalemia
curlings ulcer
paralytic ileus
hypermetabolic state
contractures
infections

What is the circulatory check?

skin color
skin temp
cap refill
pulse

What is the priority circulator assessment?

PULSE

What does turgor check?

hydration NOT circulation

What is an escharotomy?

relieves pressure and restores the circulation---cut through the eschar

What is a fasciotomy

relieves the pressure and restores the circulation but the cut is much DEEPER into the tissue-- cut through the eschar and the fascia.

How often will UO need to be monitored?

Hourly-- foley

Why would you get no urine output after inserting a foley?

It's in the vagina.
Kidneys are not producing urine b/c they are not being perfused or they are trying to conserve fluid.

What would you do if the urine is red or brown?

Call the doctor.

Why is the urine red or brown?

muscle/tissue destruction--> myoglobin release--> tints urine

What drug might be ordered to flush the kidneys?

Increased IV fluids
MANNITOL-- osmotic diuretic

What should you know about mannitol?

can crystalize in sln especially if it gets cold
utilize an in line filter
observe for CLARITY before administration
DO NOT refrigerate

What does it mean if there is no urine out put or if output is less than 30 mL/hr?

KIDNEY FAILURE

Why does the client begin to diurese after 48 hours?

Fluid returns to the vasculature, now fluid volume excess is a concern. Will see an increase in U/O

Where do we find most of out K+?

Inside the cells

What happens to a cell with burns?

They lyse and spill K+ into the serum.

What electrolyte imbalance is associated with burns?

hyperkalemia

How do you prevent a curlings ulcer?

Antacids
H2 Antagonists
Proton Pump Inhibitors

Name some antacids

Aluminum Hydroxide Gel (Amphogel)
Magnesium Hydroxied (Milk of Magnesia)

Name some H2 Anatgonists

Ranitidine (Zantac)
Famotidine (Pepcid)
Niztidine (Axid)

Name some PPI's

Pantoprazole (PRotonix)
Esomeprazole (Nexium)

What nutrients are important for wound healing?

Vitamin C
Protein

What is done to prevent/manage paralytic ileus?

NPO
NG tube hooked to suction

What causes paralytic ileus

Due to lack of blood flow. Blood is shunted away from intestines to vital organs.

What happens to a client if they don't have bowel sounds.

Increase in abdominal girth.

Will a burn pt need more calories?

Yes, they are in a hypermetabolic state.
Increased protein, calories and Vit C

For GI feedings, what should you measure to ensure that the supplement is moving through the GI tract?

Gastric residuals.
Hold feedings at 150 CC's
Always return residuals to the tum tum.

What lab work indicates proper nutrition and a positive nitrogen balance?

PREALBUMIN
total protein
albumin

What lab is best for total nutrition?

PREALBUMIN-- shows a shorter term change, more sensitive for total nurition

What about BUN?

BUN is a kidney lab, not indicative of nutrition.

What is a major complication with partial and full thickness burns?

CONTRACTURES

How do we prevent contractures?

Wrap each finger separately
Use splints
Hyper extend the neck (head back) as its healing
Don't use pillows

What is the number one complication with a perineal burn?

INFECTION

What is eschar?

dead tissue

Why is it necessary to remove eschar?

So new tissue can regenerate and it's bacterial breeding ground.

Does a burn pt get isolation?

Yes, protective or reverse

What are Sutilanis (Travase) and Collagenase (Santyl)?

enzymatic drug that eats dead tissue. Used for debridement.

What are the precautions with these debridement drugs?

Don't use on face
Don't use if pregger
Don't use over large nerves
Don't use if area is opened to a body cavity (will eat away internal organs)

Talk about hydrotherapy.

Used for debridement
VERY PAINFUL
be sure to medicate for pain before undergoing this therapy.

What are the common drugs used with burns?

Silver Sulfadiazine (Silvadene)
Mafenide Acetate (Sulfamylon)
Silver nitrate
Povidone-Iodine (Betadine)

What should we know about Silver Sufadiazine (Slivadene)?

soothing
apply directly
if rubs off apply more
can lower the WBC
can cause a rash

What should we know about Mafenide Acetate (Sulfamylon)?

can cause acid base problems
stings
if it rubs off apply more

What should we know about silver nitrate?

keep these dressings wet
can cause electrolyte problems

What should we know about Povidone-Iodine (Betadine)?

stings
stains
allergies
acid-base problems

Why should these drugs be alternated

bacteria will become tolerant or resistant

Why are broad spectrum antibiotics avoided

to prevent super bugs and secondary infections

When do you stop broad spectrum antibiotics

When you know what the culture is.

What is a broad spectrum antibiotic?

GENTIMYCIN (-MYCIN)

What are some things to worry about with -MYCIN drugs?

Ears and kidneys
Ototoxicity (hearing loss)
nephrotoxicity

Check BUN and creatinine. If increasing, assume nephrotoxic.
If UO decreasing, assume nephrotoxic.

Explain skin grafting.

Remove dead, burned tissue until healthy tissue is seen.
Take good skin from donor site and place over burned area.

What do we do with the donor site?

Cover with transparent dressing until bleeding stops, then it may be left to open air.

When can they reharvest?

If client is nourished, may harvest same donor site every 12-14 days.

What should you do if a skin graft is moved?

Call the doctor, do not place it back on the site.

What is the Q-tip rolling thing?

Order to roll sterile Q-tips over the graft with steady gentle pressure from center of graft to outer edges to get air and serous drainage out b/c they interfere with adhering the tissue graft.

What do you do with a chemical burn?

Remove client from chemical
If its a powder-- first brush it off
Next flush with water for 15-20 minutes
Don't wait for doctor to flush!

What is the first thing to do with an electrical burn?

Heart monitor for 24 hours!

What arrhythmia is this pt at high risk for?

Ventricular fibrillation!

With electrical burns, what can build up and cause kidney damage?

Hemoglobin and Myoglobin.

Why is a client with an electrical burn placed on a spine board with a C-collar?

electrical injuries occur in high places
muscle contractions can cause fractures
force of electricity can throw the victim

Why are amputations common with electrical burns?

electricity kills vascularity

What are other complications of electrical wounds?

cataracts
gait problems
any type of neurological deficit

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