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91 Cards in this Set

  • Front
  • Back
Pathophysiology of Burn Injury
* Tissue destruction = local and systemic problems
* Fluid/protein losses
* Sepsis
* Disturbances of multiple systems
* Metabolic
* Endocrine
* Respiratory
* Cardiac
* Hematologic
* Immune
* Compensatory responses
What are the Five classification of burns?
1 - Superficial
2 - Partial-thickness Superficial
3 - Partial-thickness Deep
4 - Full thickness
5 - Deep full-thickness
What are the ABA classifications
* Mild
* Moderate
* Major
* Least destruction
* ONLY epidermis affected
* Often result from prolonged exposure to low-intensity heat, e.g., sunburn
* May result from short exposure to high-intensity heat, e.g., flash burns
S/Sx of Superficial burn wounds
- mild edema
- pain
- heat sensitivity
Characteristics of superficial burn wounds
* Desquamation within 2-3 days
* Rapid healing within 3-5 days
* No scar
* No significant clinical problems
epidermis and varying depths of dermis
Partial thickness burn wounds are subdivided into what categories
- superficial partial-thickness
- deep-partial thickness
Characteristics of Superficial Partial Thickness wounds
* Increased duration/exposure to agent
* Typically erythematous/moist
* Intense pain
* Healing: 10-14 days
* blisters (vesicles)
* Intact, provides barrier
* Large numbers of blisters
Blisters occur with what type of wound?
Superficial partial thickness
* Extend deeper into dermis
* Wounds: red and waxy without vesicles
* Edema = moderate
* Pain = present (less than superficial) more nerve endings destroyed
* No vesicles
* Blood supply reduced = vasoconstriction
* May progress to deeper involvement
* Depth and involvement may increase due to infection, hypoxia, or ischemia
* Deep-partial thickness heals 3-6 wks
* Considerable scar formation
* Surgical intervention
* Skin grafts
Characteristics of FULL-THICKNESS
* Entire epidermal and dermal layers
* No epidermal tissue
* Skin grafts required (>12-16 cm2)
* Smaller sections = wound closure
* Hard,dry, leathery ESCHAR (burn crust)
* Eschar must be removed for healing
* Removal difficult
* Circumferential eschar
* Escharotomies
* Fasciotomies
Characteristics of DEEP-FULL THICKNESS
* Extend into fasica/tissues/bones/
* Flame, electrical, or chemical
* Blackened
VASCULAR CHANGES with burn wounds
* Circulatory system disruption
* Vessels occluded
* Blood flow decreases/ceases
* Tissue release chemicals
* Initially, vasoconstriction
* May lead to further injury
Fluid Shift
* Vasoconstiction then dilation
* Increased capillary hydrostatic pressure
* Increased capillary permeability
* Fluid shift: third spacing
* Plasma leaks out of CVS
* Fluid into interstitial spaces
* Loss of plasma/proteins results in decreased colloidal osmotic pressure
* Significant edema
* Inflammatory response = 24-36 hrs
* Capillary leak diminishes
* Fluid shifts back into the circulation
* Results in increased UO
* Body weight returns to normal
* Hyponatremia develops
* Increased renal sodium excretion
* Loss of sodium from wounds
* Hypokalemia (K+ returns to ICC)
* Anemia
* Fluid shifts
* Hypovolemia
* CO decreases
* HR increases
* Fluid support may be necessary
Pulmonary Changes
* Burns may results from inhalation of smoke, toxic fumes
* MAJOR cause of morbidity/mortality
* Pulmonary comps 77% patients
* Respiratory failure
* Respiratory edema
* Curling’s ulcers may form
* Fluid shifts/decreased CO = blood shifted to vital organs
* GI organs decreased perfusion
* Increased secretion of catecholamines that inhibit GI mobility
* Peristalsis decreases
* Paralytic ileus may develop
Metabolic Changes
* Hypermetabolic state results
* Increased secretion of catecholamines, ADH, aldosterone, and cortisol
* Elevated body core temp, low-grade T
* Oxygen requirements increase
* Kcal requirements increase
* May be tripled
Immunologic Changes
* Loss of protective barrier
* Increased risk for infection
* Activates inflammatory response
* Supress immune function
During vascular changes...cells begin to release ?
As the amount of circulating volume decreases, what is the effect on breathing rate, heart rate, and H & H?
- Tachypneic
- Tachycardic
- Increased H & H
* Inflammatory response
* Sympathetic nervous system response
* Helps healing
* Responsible for some complications
* Blood vessels leak and WBC releases chemicals
* Initially, helpful; harmful if continued
What are medications for Curlings ulcers?
H 2 Histamine blockers -
Cimetidine (Tagamet)
Ranitidine (Zantac)
Sucralfate (Carafate)
Etiology of Burn Injury
Name types of burn injuries...
* Dry heat
* Moist heat
* Contact burns
* Chemical injury
* Electrical injury
* Thermal
* Flash
* True electrical
* Radiation injury
What is an example of a dry heat injury? fire, explosions
What is an example of a moist heat injury? liquid
What is an example of a contact burn?
Grease, hot tar, heating pad
What is an example of a chemical injury burn?
Industrial settings, cleaning agents
What may occur with an electrical burn?
With electrical burns what are two distinct characteristics?
Entrance and exit
Interventions for burn
* Emergent Phase
* 1st hour critical
* Open airway
* Adequate circulation
* Limit extent of injury
* Maintaining functions of vital organs
* Nurse: obtain HISTORY
Physical Assessment burn
* Emergent phase and later phases
* Respiratory Assessment
* Direct airway injury
* May be observed in nares, mouth, eyes
* Hoarseness
* Cough
* Drooling/difficulty swallowing
* Lung sounds, adventitious
Assessment burn
* CO Poisoning
* Thermal Injury to Respiratory System
* From inhalation of superheated air
* Tissue damage
* Ulcerations
* Edema
* Stridor
* Dyspnea
* Smoke Poisoning
With carbon monoxide poisoning, carbon monoxide binds to what molecule?
What is the color of person's skin with carbon monoxide poisoning?
Cherry red
Assessment burn
* Pulmonary Fluid Overload
* Pulmonary edema (even without direct lung tissue involvement)
* Increased cap permeability
* Capillary fluid leakage
* Circulatory overload
* Left-sided Heart Failure
* High hydrostatic pressure
* Causes more fluid loss into ISS
* Gas exchange impaired
Minor burns
- Emergency care
- Deep partial thickness <15% TBSA
- Full thickness < 2% TBSA
- No burns of eyes, ears, face, hands, feet, perineum
- No electrical burns
- No inhalatin injury
- < 60 years of age and no chronic cardiac, pulmonary or endocrine disorder
Moderate burn
- Deep partial thickness 15%-25% TBSA
- Full thickness < 2%-10% TBSA
- No burns of eyes, ears, face, hands, feet, perineum
- No electrical burns
- No inhalatin injury
- No complicated comcomitant injury
- < 60 years of age and no chronic cardiac, pulmonary or endocrine disorder
Major burn
- Deep partial thickness >25% TBSA
- Full thickness > 10% TBSA
- Any burn involving the eyes, ears, face, hands, feet, perineum
- Electrical burns
- Inhalatin injury
- > 60 years of age
- Burn is complicated with other injuries (e.g., fracture)
- Client has cardiac, pulmonary, or other chronic metabolic disorder
Assessment burn
* Dyspnea
* Eschar from circumferential chest burns
* Put patient in position to facilitate breathing
* Thorough respiratory assessment
Assessment CVS
* Shock, monitor for s/sx (Chapter 37)
* Initially, hypovolemia and decreased CO
* Note edema
* Assess CVS
* Pulses
* VS
* Cap refill
* Oximeter
* Ekg changes
Assessment Renal
* Changes d/t decreased perfusion
* U/O diminished (even with IV)
* Sp gr increased
* Tissue damage – other substances in blood
* Destroyed RBCs release Hb and Hct
* Myoglobin (muscles) may be released
* Damaged cells release protein – uric acid
* All of these affect kidneys
Renal function assessment
* Urine output, spec grav
* Uo decreased initially
* Maintain 30-50 cc/hr
* Monitor BUN, electrolytes
Integumentary Assessment
* Total body surfact area (TBSA)
* 40% body = 40% burn
* Calculations important (meds,kcal)
* Skin assessment
* “Rule of Nines” – commonly used to determine percentage of body affected by burn injury
Integumentary Changes
* Lund-Browder (Berkow) Methods
* Very important to continually assess affected areas
* Areas may change
* Impact medications, supplies, kcal, etc
Assessment GI
* NG tube usually inserted
* Assessment: decreased bowel sounds
* Nausea, vomiting, and abdominal distention
* Ulcer formation
* Full abdominal assessment
* Stool specimen (RBC particles)
* Occult blood
Laboratory Assessment - Serum
* Hg 1.7-15.5 g/dl; 13.2 -17.3
* Hct 25-45; 40-60%
* Electrolytes
* ABGs
* Other
* Total protein
* albumin
Emergency Management - General
* Assess for airway patency
* Oxygen
* Cover client with blanket
* Elevate affected part if no fx
* VS
* IV
* History/assessment
* Tetanus, prophylactically
Decreased CO, Tissue Perfusion & FVD
Planning: Expected Outcomes
* Emergency phase: restore CO
* Maintain oxygenation/perfusion
Interventions for decreased cardiac output, tissue persuion, and fluid volume deficit
* Aimed at increasing fluid volume
* Supporting compensatory mechanisms
* Preventing complications
Fluid Monitoring
* Monitor serum electrolytes/UA
* Monitor VS
* Monitor changes in cardiac status
* Ekgs
* Monitor weight
* Accurate I&O
* Note any vertigo/syncope
* Specific gravity, quality of urine output
Nursing Interventions for fluid monitoring
* Aimed at increasing fluid volume, supporting compensatory mechanisms, and preventing complications
* Nonsurgical management –
* Intravenous Fluid Therapy
* 15-20% burns typically require IV therapy
* Many different formulas for IV therapy
* Be familiar with different type names
* IV therapy used to prevent ?
* Severe burn – large fluid loads quickly
* Boluses are avoided, why?
* Usually, calculated based on time of injury
* Known as “resuscitation” therapy
- shock
- increases cap hydrostatic pressure and exacerbates edema
Plasma Exchange Therapy
* Shock/persistent shock (eti unknown)
* Used in burn centers for patients with massive burns who fail to respond
* Remove plasma/add FFP “plasmapheresis”
* Remove blood/add blood
* Clinical criteria
* Monitor all systems
* Urine output is the most common and most sensitive noninvasive assessment parameter for CO and T perfusion
* IV rate must sustain 30ml/hr
* Titration of IV to perfuse adequately
* >35% burns, uo and VS inadequate
* Invasive cardiac monitoring necessary
Hypovolemic shock
* Extensive cardiac monitoring
* CVP (central venous pressure), PAP (pulmonary artery pressure), and CO
* Nurse monitors EKG/ECG
* Atrial fib and other abnormalities may be seen
Drug Therapy
*common mistake – administer diuretics which can reduce perfusion to other organs (diuretics do not increase CO; they decrease volume and thus CO by pulling fluid from circulating volume to enhance diuresis)
* Exception: electrical burns
* Mannitol may be given AFTER u/o est
* Problems: CHF or MI
Surgical Management
* Escharotomy = incision through burn eschar
* Relieves pressure
* If not relieved, arterial compression with irreversible damage
* Compromised perfusion
* Ischemia
* Necrosis
* If insufficient, may need fasciotomy (deeper)
* Performed at bedside
* No anesthesia
* Sedation/analgesia, « anxiety
* Dressings
* Topical antimicrobial agents
* Carefully monitored for bleeding, infection, inflammation, changes
Ineffective Breathing Pattern
* Outcome: airway patency
* Interventions
* Nonsurgical
* Promote airway clearance
* Promote ventilation
* Promote gas exchange
* O2 therapy
* Drug therapy
* Positioning
* Deep breathing
Airway Maintenance
* Chin lift/repositioning head of unconscious victim at scene
* Upper airway edema – intubation
* Bronchoscopy to view structures
* Endotracheal tube
* Monitor secretions/sloughed off tissue from lungs which can obstruct airway
* Rigorous Suctioning necessary but painful (sedation required beforehand)
Promotion of Ventilation
* Depends on pertinent muscles, etc.
* Many burn dressings restrictive
* Monitoring Gas Exchange
* Laboratory tests
* Physical assessment
* Chest x-ray
* Cardiac monitoring
Oxygen Therapy for airway maintenance
* Administering humidfied O2 by face mask, cannula, or hood
* Arterial oxygenation <60PaO2, intubation and mechanical ventilation
* Airway equipment at bedside
Drug Therapy for airway maintenance
* Antibiotics may be prescribed
* Paralytic drugs
Positioning and Deep Breathing for airway maintenance
* Turned, repositioned, OOB
Surgical management for airway maintenance
* Tracheostomy –long term intubation
* Chest tubes – to reexpand lungs
Acute/Chronic Pain
* From burns and treatments
* Pain assessment scales
* Medications
* Diversional/alternative pain modalities
* Important to alleviate/monitor pain
* One of the MAJOR issues!
Drug Therapy for acute/chronic pain
* Opioid and nonopioid analgesics (morphine)
* Problem: respiratory depression
* Diminished GI motility
* Emergent phase: IV pain medications preferred (give GI tract rest)
* IM – remain in skin, are not absorbed
* Edema - fluid impairs absorption
* Strict protocols for all medications
Complementary and Alternative Tx for acute/chronic pain
* Relaxation
* Focused breathing
* Guided visual imagery
* Music
* Massage/therapeutic touch
Environmental Manipulation for acute/chronic pain
* Quiet, restful, calm environment
* Increase patient’s control
* Sleep deprivation
* Plan care to provide rest/sleep
* Tactile stimulation, may reduce pain
* Changing position
* Warm room temperatures
* Patient involvement
Pulmonary Edema
* Outcome
* Interventions
* May affect even young patients
* Digoxin or another inotropic medication to improve left ventricular function
* Diuretics, may/may Not be used depending on renal function
* Outcome: ABGs wnl
* Interventions aimed at increasing lung compliance
* Improving ABGs
* PEEP to augment decreasing lung volume by providing continuous PP in the airways to alveoli
* Maximizes gas exchange
* Monitor respiratory status
Phases of Burn Injury
- Emergency
- Acute phase
- Rehabilitative phase
Emergency Phase
* First 48 hours
* Maintain an open airway, ensure adequate breathing/circulation
* Limit extent of injury/maintain function of vital organs
* Prevent potential complications
Acute phase
* First 48 hours to complete wound closure
* Maintenance of cardiovascular/respiratory systems
* Nutritional status
* Burn wound care
* Pain control
* Psychosocial interventions
Interventions for Burn Wound Management - nonsurgical
- Debridement
- Dressings
Types of Debridement
- Mechanical
- Enzymatic
Types of Dressings
- Standard wound dressings
- Biologic dressings
- Synthetic dressing/artificial skin
Interventions - surgical
- Surgical excision
- Wound coverings
Surgical management
* For contractures is restorative
* Most common in neck, axilla, elbow, hand
* Improves movement
* Postop care
* Prevention of further contractures
* Body Image Disturbance
Body Image Distrubance
* Serious problem
* Nonsurgical management
* Nurse–stages of grief understanding and intervention to assist patient
* Patient often confused
* Patient may be angry, anxious, etc.
* Nurse must be strong and able to interpret patient’s feelings without internalizing
* Assurance to patient feelings are normal
* May need to provide referral
* Nurse must accept patient’s physical appearance
* Work with family/groups
- reconstructive surgery
* Cosmetic surgery
* May be performed for many years
* Restoration of function/appearance
* Increases patient’s feelings of self-worth
* Patients may have unrealistic expectations, education critical
* Nurse – continually assess patient for s/sx infection
* Gram+, gram -, fungal infections
* Local and systemic s/sx infection
Burns-Nursing Diagnosis
* Decreased cardiac output
* Deficient fluid volume
* Ineffective tissue perfusion (multiple)
* Ineffective breathing pattern
* Pain
* Excess fluid volume
* Risk for ineffective thermoregulation
* Sensory/perceptual alterations
Vesicles...which type of wound?
Superficial partial thickness
Red and waxy without vesicles...what type of wound?
Deep partial thickness
Black eschar?
Deep full thickness
Sunburn, example of?
Superficial wound
Nerve endings exposed?
Deep superficial partial thickness