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68 terms

Ch 25 - Burns - Nursing/Collaborative - Emergent Phase

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
wound care
Emergent Phase - initial positioning
proper positioning
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
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
Emergent Phase - if respiratory failure
mechanical ventilation
positive end-expiratory pressure to prevent collapse of aveoli & progressive respiratory failure
Emergent Phase - for severe bronchospasm
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
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
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
some newer antimicrobial dressing can be left in place from 3-14 days
Emergent Phase - Wound Care - most serious threat
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
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
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
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
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
ABGs - to dermine ventilation & perfusion with inhalation or electrical injury
Emergent Phase - other nursing care measures - PT - when
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