Class 8: Burn Patient

Created by jusme6 

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95 terms

Protection, Fluid and Electrolyte Balance, Thermoregulation, Metabolism, Neurosensory, Immunologic, Social and Interactive

Functions of the Skin:
1. ____________: 1st line of defense
2. ____________: releases sodium, uria, uric acid
3. ____________: shunts blood toward/away from core
4. ____________: skin breakdown -> catabolism
5. ____________: touch receptors, pain receptors, thermoreceptors
6. ____________: Langerhans cells
7. ____________: how do I look?

600 - 900 ml

Amount of water lost each day through the skin (insensible perspiration).

Prevention, lifesaving, disability, disfigurement, reconstructive,

Major Goals Related to Burns
1. ____________
2. Institution of __________ measures for the severely burned person.
3. Prevention of __________ and __________.
4. Rehabilitation through __________ surgery and rehabilitation.

prevention, pound

Prevention:
"An ounce of _________ is worth a __________ of cure."

thermal burn

Type of burn injury caused by flame, flash, scald, contact with hot objects

chemical burn

Type of burn injury caused by acid, alkali, organic compounds

smoke inhalation injury

Type of burn injury resulting from the inhalation of hot air or noxious airborne chemicals and can cause damage to the tissues of the respiratory tract.

electrical burns

Type of burn caused by an electrical current

clean, cool, water-dampened

For small thermal burns, cover with ___________, __________, ______________ towel.

ice

Never put _____ on a burn.

causes of Thermal Burns

-Hot tar
-Hot grease
-Hot (Molten) metal
-Hot liquids

Accidental burn

Children in developing countries often fall victim to this type of thermal burn. The affected skin has various discolorations and borders.

Intentional burn

An unlikely story is often used to explain this type of burn on a child. The affected skin is uniform in color for the most part and has perfect borders.

capillaries

The redness of a burn is caused by rupture of ___________.

skin, water, cloths, 72, ARDS

Nursig considerations for a chemical burn:
-Remove quickly from the ______
-Flush with _______
-Remove ________ if chemicals are on it
-Tissue destruction may continue for ____ hours
-Inhalation -> complications of _______

Chemical burns

This type of burn is caused by
-Acids
-Alkilis (worse than acid)

types of Smoke Inhalation Injuries

-Carbon monoxide poisoning
-Inhalation injury above the glottis
-Inhalation injury below the glottis

sources of Carbon Monoxide (CO)

-House fires
-Faulty furnaces
-Heaters
-Wood-burning stoves
-Motor vehicle exhaust
-Propaine-fuled equipment
-Gas-powered tools

Carbon Monoxide

_______ ______ is a poisonous gas that has a higher affinity for hemoglobin than does oxygen.

buildings, semi-enclosed

There is an increased risk for carbon monoxide poisoning in __________ or ____________ spaces.

Carbon Monoxide poisoning s/s

Early: headaches, fatigue, nausea (flu-like effects)
Later (depending on cencentration): Progresses to tachycardia, HTN, CNS symptoms (confusion, convulsions, repsiratory arrest, death)

Carbon monoxide (CO)

One of the best ways to prevent carbon monoxide poisoning is to install _________ _________ detectors in houses and buildings.

treatment for Carbon monoxide poisoning

-100% oxygen by a non re breather reservoir oxygen mask
-Hyperbaric oxygen (controversial: may cause toxicity: epistaxis (nose bleeding), otorrhagia (ear bleeding))
-supportive care for symptom management

thermally, air, steam, smoke, oropharynx, larynx

Inhalation injury above the glottis
-_________ produced
-Inhalation of hot ________, ________, or ________
-Mucosal burns: ________ & ________ redness, blistering, edema, mechanical obstruction

chemically, lower, 12 - 24, ARDS

Inhalation injury below the glottis
-_________ produced
-Tissue injury to _______ repsiratory tract
-Pulmonary edema: __________ hours after the burn --________

indicators of Smoke Inhalation Injury

-The burns occurred in an enclosed area
-Burns of the face or neck
-Singed nasal hair
-Hoarsness, voice change, dry cough
-Bloody or sooty sputum
-Tachypnea, labored breathing, painful swallowing
-Erethema and blistering of the oral or pharyngeal mucosa
-Complications: ARDS, pulmonary edema

Electrical Burn

For this type of burn...
-Damage may not be apparent for several days
-DC currents want to leave the body through the ground itself
-Iceburn effect: most of the damage is below the skin
-Priority is to remove the person from contact with the source without being burned

voltage, resistance, pathway, surface, duration

Severity of an electrical burn depends on
-Amount of _______
-Tissue _______: bone & fat > nerves & blood vessels
-_______ the current takes through the body
-_______ area in contact with the current
-_______ of flow (length of time)

bone, fat, nerves, blood vessels

Tissue densities offer various amounts of resistance to electric current. For example, ________ and _______ offer the most resistance, whereas _________ and _________ offer the least resistance.

building, enclosed, metal

Safest Locations in a Lightening Storm
1) ________ that is fully enclosed
2) ________ metal vehicle (car, truck van), doors closed, windows up, do not touch ________ surface

interventions for Electrical Burns

-Safely remove patient from source using non-conductive materials (wood, rubber)
-ABCs with spinal precautions: watch for for head and spinal cord injuries, open airway with jaw thrust
-AMI workup: electricity conducted through muscle causes contraction

size, age, inhalation

Three main factors in determining burn mortality:
1) ______ of the burn
2) ______ of the patient
3) Presence of smoke ________.

higher

Burn victims who are much younger or older have a ________ risk for mortality.

24 hrs

Within the first _____ after a burn, the priority is treating hypovolemic shock. Afterwards, the priority is treating septic shock.

Depth, Size, Location

Classification of Burns: Burn injuries are described according to:
-_______ of the tissue injury
-_______ of the burn/extent (%) of total body surface area (TBSA) injured
-_______ of the burn on the body
-Patient risk factors (older adult, CV disease, respiratory disease, renal disease, DM, PVD, alcoholism, drug abuse, malnutrition, fractures, head injuries, other trauma)

poor prognosis factors for Burns

-Older adult
-Preexisting cardiovascular, respiratory, or renal disease
-Diabetes mellitus, peripheral vascular disease: gangrene
-General physical debilitation from any chronic disease including alcoholism, drug abuse, or malnutrition
-Currently sustaining fractures, head injuries, or other trauma.

Superficial

Normal assessment results of this type of burn include:
-Dry
-No blisters (may blister and peel after 24 hrs)
-Minimal edema
-Delayed pain

Superficial Partial Thickness

Normal assessment results of this type of burn include:
-Weeping
-Moist blebs
-Red
-Very painful

Deep Partial Thickness

Normal assessment results of this type of burn include:
-Thick walled blister
-Wet looking

Full Thickness

Normal assessment results of this type of burn include:
-Dry
-Eschar
-May look charred

superficial

_________ (1st degree) burns are not calculated in the extent of the burn.

Rule of Nines

Method used for initial assessment of adult patients:
-Total SA of head = 9%
-Total SA of upper limbs = 18%
-Total SA of anterior and posterior trunk = 36%
-Total SA of the perineum = 1%
-Total SA of lower limbs = 36%

4.5 %

According to the "rule of nines," each upper limb's anterior surface area is ____ of the total body surface area. This is the same as the limb's posterior surface area.

9 %

According to the "rule of nines," each lower limb's anterior surface area is ____ of the total body surface area. This is the same as the limb's posterior surface area.

4.5 %

According to the "rule of nines," the anterior surface area of the head is ____ of the total body surface area. This is the same as the heads posterior surface area.

9 %

According to the "rule of nines," the surface area of the chest (anterior) is ____. This is the same as the surface area of the upper back.

9 %

According to the "rule of nines," the surface area of the abdomen (anterior) is ____ of the total body surface area. This is the same as the surface area of the lower back.

1 %

According to the "rule of nines," the surface area of the peritoneum is ___ of the total body surface area.

Phases of Burn Management

-Pre-hospital
-Emergent (resuscitative)
-Acute (wound healing)
-Rehabilitative (restorative)

Pre-hospital

In this phase of burn management:
-Protect the rescuer
-Remove person from source of burn
-Stop the burning process

Emergent (Resuscitative) Phase

In this phase of burn management:
-Resolve immediate life-threatening problems
-Lasts from the time of burn to 3 to 4 days
-Primary concern = hypovolemic shock and edema formation (risk for compartment syndrome)
-Continues until fluid immobilization and diuresis begin

capillary, colloidal osmotic pressure, hemolyzed, cells, blood, blood, cells

Emergent Phase: Pathopysiology
Fluid & Electrolyte Shifts:
-Increased ________ permeability -> massive shift of fluids from the intravascular space to the interstitial space.
-_______ ________ _________ decreases - net result: edema, hypotension, tachycardia, hypovolemic shock
-RBCs are __________ -> thrombosis
-increased Hct (due to plasma loss)
-K shift -> out of _____ -> into _____
-Na shift -> out of _____ -> into _____
-Immunologic changes

bone marrow, immunoglobulins, WBCs, cytokine, lymphocytes, monocytes, neutrophils

Burn injury causes widespread impairment of the immune system. The skin barrier to invading organisms is destroyed, resulting in _________ ________ depression and decreased circulating levels of __________. Defects occur in the function of ______. The inflammatory ________ cascade triggered by tissue damage impairs the function of ___________, ___________, and ___________, which puts the patient at greater risk for infection.

Emergent Phase s/s

-Shock from pain and hypovolemia
-Blisters, edema
-Adynamic ileus (paralytic ileus)
-Shivering
-Altered mental status due to hyupoxia, head trauma, excessive pain meds

Adynamic ileus

Another term for "paralytic ileus" which starts with an "a."

cardiovascular, respiratory, urinary

Three major organ systems most susceptible to complications during the emergent phase of burn injury are the ___________, __________, and _________ systems.

compartment syndrome, escharotomy

Cardiovascular system complications include dysrhythmias and hypovolemic shock, which may progress to irreversible shock. Circulation to the extremities can be severely impaired by circumferential burns and subsequent edema formation. These processes occlude the blood supply (______ ________), causing ischemia, paresthesia, necrosis, and eventually gangrene. An ___________ is frequently performed following transfer to a burn nit to restore circulation to compromised extremities.

escharotomy

A scalpel incision through full-thickness eschar.

local, systemic

Complications: Burn Edema
-_______ edema if burn is < 25% of TBSA.
-_______ edema with severe burns.

complications of Emergent Phase

-Cardiovascular System: dysrhythmias, shock, edema, paresthesia, ischemia, necrosis, increased viscosity of microciculation
-Respiratory system: airway obstruction=upper airway; inhalation injury=lower airway (pneumonia, pulmonary edema)
-Urinary system: hemoglobin in urine (RBC destruction), myoglobin in urine (if muscle cells are destroyed), risk for acute tubular necrosis (ATN) and renal failure
-Impaired immune response
-Inability to regulate body temperature: hypothermic (in early hours post burn), hyperthermic (during hypermetabolic period)
-GI complications: paralytic ileus, Curling's ulcer

complications of Acute Phase

-Infection
-Cardiac:dysrhythmias, shock, edema, paresthesia, ischemia, necrosis, increased viscosity of microciculation
Respiratory: airway obstruction-upper airway, inhalation injury-lower airway, pneumonia, pulmonary edema
-Neurological: disorientation, withdrawn behavior, combative behavior, hallucinations, nightmares, delirium (older), psychosis, ICU syndrome
-Musculoskeletal: Contractures (tx with splinting)
-Gastrointestinal: Curling's ulcer, diarrhea (antibiotics), constipation (narcotics), occult blood in stool
-Endocrine: increased cortisol, increased glucose, increased insulin, decreased insulin sensitivity,(increased cortisol and/or increased feedings -> decreased insulin sensitivity; treat with IV insulin)

sludging

Initially, there is an increase in blood viscosity with burn injuries because of the fluid loss that occurs in the emergent period. Microcirculation is impaired because of the damage to skin structures that contain small capillary systems. These two events result in a phenomenon termed __________. This can be corrected by adequate fluid replacement.

Compartment syndrome

A limb-threatening and life-threatening condition observed when perfusion pressure falls below tissue pressure in a closed anatomic space. Untreated, this condition leads to tissue necrosis, permanent functional impairment, and, if severe, renal failure and death.

Curling's Ulcer

An ulcer of the duodenum in a patient with extensive superficial burns or severe bodily injury.

treatment for Curling's Ulcer

-NG tube: pump gastric contents
-ranitidine (Zantac)

Airway management for Emergent Phase

-Early endotracheal intubation
-Escharotomy of the chest wall relieves respiratory distress
-Bronchoscopy
-100% humidified oxygen in CO poisoning
-ABG monitoring

fluid therapy for Emergent Phase

-One or two large-bore IV lines (14g, 16g)
-Urinary catheter, monitor I/O
-Type of fluid replacement based on size/depth of burn, age, and individual considerations
-Parkland (Baxter) formula for fluid replacement
-Crystalloid solutions: LR
-Colloidal solutions: Albumin

fluid resuscitation for Emergent Phase

4 ml x kg x TBSA% = 24 hrs LR to be infused
-Half of the calculated total is given over the first 8 hours post-burn
-The other half is given over the next 16 hours
-Fluid is administered at a rate to produce 30 - 50 ml of urine output per hour
-Survival depends on adequate fluid

30 - 50 ml/hr, 90 - 100 mm Hg, 110 - 120/min, clear yellow, 1.003 - 1.030

The adequacy of fluid resuscitation is determined by:
1) Urine output of ________
2) SBP > _______
3) Pulse rate < ________
4) _______ _______ urine with specific gravity _________

complications of under-rehydration

-Inadequate organ perfusion
-Acute tubular necrosis
-Stress ulcers (Curling's ulcer)

complications of over-rehydration

-Pulmonary edema
-Excessive wound edema
-Generalized edema

thermoregulation for Emergent Phase

-Provide warm environment (85F 29.4C)
-Monitor temperature
-Work quickly when wounds are exposed
-Goal: maintain adequate body temperature

pain management for Emergent Phase

-Use pain intensity scale
-IV narcotic analgesic: morphine sulfate (analgesic of choice), titrated based on patient's self-report of pain, hydromorphone (Dilaudid)
-Monitor respirations and effectiveness of medication
-Goal: Control of pain
-Types of pain -> drug combinations used: background or resting pain, procedural pain, breakthrough pain
-Anxiolytics: Lorazepam (Ativan), Midazolam (Versed)
-Antipsychotics: Haloperidol (Haldol) -> produces antipsychotic and sedative effects, promotes sleep

non-pharm pain management for Acute Phase

-Visualization (Guided Imagery)
-Hypnosis
-Relaxation techniques
-Transcutaneous electrical nerve stimulation (TENS)
-Acupuncture
-Biofeedback
-Auditory (music)
-Activities (video games)

infection management for Emergent Phase

-Antimicrobial agents (topical): Silver sulfadiazine (Silvadene), Mafenide acetate (Sulfamylon)
-Systemic agents not usually used in controlling burn flora. Initiated when diagnosis of invasive burn would sepsis is made

psychological management for Emergent Phase

-Heavily sedated initially
-Explanations
-Maintain eye contact
-Emotional support
-Anti-anxiety medications

wound care for Emergent Phase

-Cleansing
-Debridement: mostly done in shower, initial debridement may take several hours, surgeon debrides skin down to fresh granulation tissue
-Should be delayed until a patent airway, adequate circulation, and adequate fluid replacement have been established
-Shower, bed bath or immersion in a tank/tub
-Longer than 20 to 30 minutes can cause electrolyte loss from open burned areas
-When open burns/wounds are exposed, staff should wear disposable hats, masks, gowns, gloves

Allograft/Homograft

A tissue graft from an organism of the same species as the recipient, but the donor is genetically unrelated to the recipient. Usually obtained from cadavers and typically used with newer biosynthetic options.

Heterograft/Xenograft

A tissue graft obtained from a donor of a different species from the recipient. Usually pig skin.

Autograft

a tissue graft obtained from one part of a patient's body for use on another part

Cultured Epithelial Autograft (CEA)

Procedure that takes skin cells from the patient to grow new skin cells in sheets in a laboratory. The new sheets are used as grafts, and because the original skin cells came from the patient, the body does not reject them.

nutritional management of Emergent Phase

-Fluid replacement takes priority over nutritional needs
-Early and aggressive nutritional support within hours of burn injury -> decreases mortality and complications -> optimize wound healing
-Feed as soon as bowel sounds are present
-Hypermetabolic state: Resting metabolic expenditure may be increased by 50% to 100% above normal
-Core temperature is elevated: Acetaminophen for fever
-Caloric needs are about 5000 kcal/day
-High calorie, high protein

Acute Phase

In this phase of burn management:
-The beginning is marked by the mobilization of extracellular fluid and subsequent diuresis-Diuresis from fluid mobilization occurs
-Bowel sounds return
-Healing begins when WBCs have surrounded the burn wound and phagocytosis
-The patient may now become aware of the enormity of the situation
-The end is marked by when the burned area is completely covered by skin grafts or when the wounds are healed

hyponatremia

____________ can occur if hydrotherapy is too lengthy because the hypotonicity of the bath water pulls sodium from open burn areas. Other causes include excessive GI suction, diarrhea, and excessive water intake. Manifestations include weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, and confusion.

hypernatremia

____________ may bee seen following successful fluid replacement if copious amounts of hypertonic solutions were required. Other causes include improper tube feeding therapy or inappropriate fluid administration. Manifestations include thirst; dried, furry tongue; lethargy; confusion; and possibly seizures.

hyperkalemia

____________ is noted if the patient has renal failure, adrenocortical insufficiency, or massive deep muscle injury. Cardiac dysrhythmias and ventricular failure can occur. Muscle weakness and electrocardiographic (ECG) changes are observed clinically.

hypokalemia

____________ (e+ imbalance) occurs with vomiting, diarrhea, prolonged GI suction, and prolonged IV therapy without supplementation. A constant loss occurs through the burn wound.

ICU syndrome

A disorder in which patients in an intensive care unit (ICU) or a similar setting experience a cluster of serious psychiatric symptoms. It is also a form of delirium, or acute brain failure.

wound care for Acute Phase

-Daily observation
-Assessment
-Cleansing
-Debridement
-Dressing reaplication
-Excision and grafting

10 - 14 days

The average healing time for a skin graft donor site is _________.

interventions for Acute Phase

-Pain management: Drug therapy & non pharmacologic interventions
-Physical and occupational therapy
-Nutritional therapy: high protein, high carbohydrate diet; weighed regularly
-Psychosocial care

Rehabilitation Phase

In this phase of burn management:
-The beginning is when the patient's burn wounds are covered with skin or healed and the patient is able to resume a level of self-care activity.
-Wounds heal by primary intervention or grafting
-Mature healing is reached in 6 months to 2 years
-Skin never completely regains its original color; hyper or hyposensitive
-Pressure can help keep the scar flat
-Custom-fitted pressure garments 24 hours a day for 12 to 18 months
-Protect from direct sunlight for 1 year

deep, turning, proper, passive, active, sitting, ambulation

Prevent Complications from immobility:
-______ breathing
-______
-______ re-positioning
-______ and ______ ROM
-Early ______ and ______
-Splints

secondary complications of Acute Phase

-Post Traumatic Stress Syndrome
-Sleep disturbance
-Nightmares
-Depression
-Body image disturbance
-Itching from scar tissue

patient, family, nursing staff

List of people with emotional needs following a burn injury.
1)________
2)________
3)________ _________

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