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Acute wk 8 - Burns practice/PP

Terms in this set (92)

The intermediate phase of burn care begins about 48-72 hours following the burn injury. Changes in capillary permeability and a return of osmotic pressure bring about diuresis or increased urinary output. If renal and cardiac functions do not return to normal, the added fluid volume, which prevented hypovolemic shock, might now produce symptoms of congestive heart failure. Assessment of central venous pressure provides information regarding the client's fluid status.

Infections represent a major threat to the post-burn client. Bacterial infections (staphylococcus, proteus, pseudomonas, escherichia coli, and klebsiella) are common due to optimal growth conditions posed by the burn wound; however, the primary source of infection appears to be the client's own intestinal tract. As a rule, systemic antibiotics are avoided unless an actual infection exists.
Additional complications found during the intermediate phase include infections, the development of Curling's ulcer, paralytic ileus, anemia, disseminated intravascular coagul

During the intermediate phase, attention is given to removing the eschar and other cellular debris from the burned area. Debridement, the process of removing eschar, can be done placing the client in a tub or shower and gently washing the burned tissue away with mild soap and water or by the use of enzymes, substances that digest the burned tissue. Santyl (collagenase) is an important debriding agent for burn wounds.

The central venous pressure (CVP) is read with the client in a supine position

Following debridement, the wound is treated with a topical antibiotic and a dressing is applied (more on dressings is covered in the next section).
Begin immediately after the burn has occurred

Healing, psychosocial support, and restoring maximum functional activity remain priorities.

Maintaining fluid and electrolyte balance and improving nutrition status.

Perform ongoing assessments goals, range of motion of affected joints, ADLs, skin breakdown/neuropathies activity tolerance, and quality of healing skin.

Protect skin from sunburn.

Wear custom fit pressure garments only over healed wounds. Leave on 23/hrs. a day for 12-24 months

Assess for early detection of complications

...Rehabilitation Phase

Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status continue to be important.

In early assessment, obtain information about patient's educational level, occupation, leisure activities, cultural background, religion, and family interactions.
Assess self concept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern.
Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin.
Document participation and self care abilities in ambulation, eating, wound cleaning, and applying pressure wraps.
Maintain comprehensive and continuous assessment for early detection of complications, with specific assessments as needed for specific treatments, such as postoperative assessment of patient undergoing primary excision.
Acute respiratory failure:
Assess for increasing dyspnea, stridor, changes in respiratory patterns; and assist as needed with intubation or escharotomy.

Distributive shock: Monitor for early signs of shock or progressive edema.
Administer fluid resuscitation as ordered in response to physical findings; continue monitoring fluid status.

Acute renal failure: Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN) and creatinine levels; assess for urine hemoglobin or myoglobin; administer increased fluids as prescribed.

Compartment syndrome: Assess peripheral pulses hourly with Doppler; assess neurovascular status of extremities hourly; elevate burned extremities; report any extremity pain, loss of peripheral pulses or sensation; prepare to assist with escharotomies.

Paralytic ileus: Maintain nasogastric tube on low intermittent suction until bowel sounds resume; auscultate abdomen regularly for distention and bowel sounds.

Curling's ulcer: Assess gastric aspirate for blood and pH; assess stools for occult blood; administer antacids and histamine blockers (eg, ranitidine [Zantac]) as prescribed.

...An escharotomy is a surgical procedure used to treat full-thickness (third-degree) circumferential burns. In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar

Curling's ulcer (stress ulcer) or a Curling ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. ... A similar condition involving elevated intracranial pressure is known as Cushing's ulcer