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91 Cards in this Set
- Front
- Back
Pathophysiology of Burn Injury
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* Tissue destruction = local and systemic problems
* Fluid/protein losses * Sepsis * Disturbances of multiple systems * Metabolic * Endocrine * Respiratory * Cardiac * Hematologic * Immune * Compensatory responses |
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What are the Five classification of burns?
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1 - Superficial
2 - Partial-thickness Superficial 3 - Partial-thickness Deep 4 - Full thickness 5 - Deep full-thickness |
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What are the ABA classifications
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* Mild
* Moderate * Major |
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Superficial-thickness
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* 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 |
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S/Sx of Superficial burn wounds
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- mild edema
- pain - heat sensitivity |
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Characteristics of superficial burn wounds
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* Desquamation within 2-3 days
* Rapid healing within 3-5 days * No scar * No significant clinical problems |
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PARTIAL-THICKNESS
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epidermis and varying depths of dermis
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Partial thickness burn wounds are subdivided into what categories
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- superficial partial-thickness
- deep-partial thickness |
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Characteristics of Superficial Partial Thickness wounds
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* Increased duration/exposure to agent
* Typically erythematous/moist * Intense pain * Healing: 10-14 days * blisters (vesicles) * Intact, provides barrier * Large numbers of blisters |
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Blisters occur with what type of wound?
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Superficial partial thickness
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Characteristics of DEEP-PARTIAL THICKNESS
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* 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 |
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Characteristics of FULL-THICKNESS
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* 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 |
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Characteristics of DEEP-FULL THICKNESS
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* Extend into fasica/tissues/bones/
* Flame, electrical, or chemical * Blackened |
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VASCULAR CHANGES with burn wounds
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* Circulatory system disruption
* Vessels occluded * Blood flow decreases/ceases * Tissue release chemicals * Initially, vasoconstriction * May lead to further injury |
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Fluid Shift
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* 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 |
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Fluids
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* 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 |
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CVS
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* Fluid shifts
* Hypovolemia * CO decreases * HR increases * Fluid support may be necessary |
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Pulmonary Changes
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* Burns may results from inhalation of smoke, toxic fumes
* MAJOR cause of morbidity/mortality * Pulmonary comps 77% patients * Respiratory failure * Respiratory edema |
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GI
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* Curlings 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 |
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Metabolic Changes
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* 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 |
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Immunologic Changes
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* Loss of protective barrier
* Increased risk for infection * Activates inflammatory response * Supress immune function |
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During vascular changes...cells begin to release ?
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toxins
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As the amount of circulating volume decreases, what is the effect on breathing rate, heart rate, and H & H?
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- Tachypneic
- Tachycardic - Increased H & H |
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COMPENSATORY RESPONSES
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* Inflammatory response
* Sympathetic nervous system response |
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Inflammatory
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* Helps healing
* Responsible for some complications * Blood vessels leak and WBC releases chemicals * Initially, helpful; harmful if continued |
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What are medications for Curlings ulcers?
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H 2 Histamine blockers -
Cimetidine (Tagamet) Ranitidine (Zantac) Sucralfate (Carafate) |
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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 |
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What is an example of a dry heat injury?
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Flame...house fire, explosions
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What is an example of a moist heat injury?
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Scald...hot liquid
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What is an example of a contact burn?
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Grease, hot tar, heating pad
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What is an example of a chemical injury burn?
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Industrial settings, cleaning agents
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What may occur with an electrical burn?
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Amputation
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With electrical burns what are two distinct characteristics?
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Entrance and exit
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Interventions for burn
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* Emergent Phase
* 1st hour critical * Open airway * Adequate circulation * Limit extent of injury * Maintaining functions of vital organs * Nurse: obtain HISTORY |
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Physical Assessment burn
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* 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 |
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Assessment burn
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* CO Poisoning
* Thermal Injury to Respiratory System * From inhalation of superheated air * Tissue damage * Ulcerations * Edema * Stridor * Dyspnea * Smoke Poisoning |
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With carbon monoxide poisoning, carbon monoxide binds to what molecule?
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Hemoglobin
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What is the color of person's skin with carbon monoxide poisoning?
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Cherry red
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Assessment burn
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* 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 |
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Minor burns
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- 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 |
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Moderate burn
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- 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 |
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Major burn
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- 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 |
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Assessment burn
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* Dyspnea
* Eschar from circumferential chest burns * Put patient in position to facilitate breathing * Thorough respiratory assessment |
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Assessment CVS
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* Shock, monitor for s/sx (Chapter 37)
* Initially, hypovolemia and decreased CO * Note edema * Assess CVS * Pulses * VS * Cap refill * Oximeter * Ekg changes |
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Assessment Renal
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* 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 assessment |
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Renal function assessment
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* Urine output, spec grav
* Uo decreased initially * Maintain 30-50 cc/hr * Monitor BUN, electrolytes |
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Integumentary Assessment
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* 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 |
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Integumentary Changes
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* Lund-Browder (Berkow) Methods
* Very important to continually assess affected areas * Areas may change * Impact medications, supplies, kcal, etc |
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Assessment GI
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* NG tube usually inserted
* Assessment: decreased bowel sounds * Nausea, vomiting, and abdominal distention * Ulcer formation * Full abdominal assessment * Stool specimen (RBC particles) * Occult blood |
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Laboratory Assessment - Serum
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* Hg 1.7-15.5 g/dl; 13.2 -17.3
* Hct 25-45; 40-60% * Electrolytes * ABGs * Other * Total protein * albumin |
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Emergency Management - General
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* Assess for airway patency
* Oxygen * Cover client with blanket * NPO * Elevate affected part if no fx * VS * IV * History/assessment * Tetanus, prophylactically |
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Decreased CO, Tissue Perfusion & FVD
Planning: Expected Outcomes |
* Emergency phase: restore CO
* Maintain oxygenation/perfusion |
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Interventions for decreased cardiac output, tissue persuion, and fluid volume deficit
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* Aimed at increasing fluid volume
* Supporting compensatory mechanisms * Preventing complications |
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Fluid Monitoring
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* 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 |
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Nursing Interventions for fluid monitoring
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* 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 |
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* 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 |
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Plasma Exchange Therapy
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* 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 |
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Monitoring
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* 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 |
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Hypovolemic shock
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* 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 |
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Drug Therapy
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*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 |
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Surgical Management
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* 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 |
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Ineffective Breathing Pattern
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* Outcome: airway patency
* Interventions * Nonsurgical * Promote airway clearance * Promote ventilation * Promote gas exchange * O2 therapy * Drug therapy * Positioning * Deep breathing |
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Airway Maintenance
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* 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) |
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Promotion of Ventilation
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* Depends on pertinent muscles, etc.
* Many burn dressings restrictive * Monitoring Gas Exchange * Laboratory tests * Physical assessment * Chest x-ray * Cardiac monitoring |
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Oxygen Therapy for airway maintenance
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* Administering humidfied O2 by face mask, cannula, or hood
* Arterial oxygenation <60PaO2, intubation and mechanical ventilation * Airway equipment at bedside |
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Drug Therapy for airway maintenance
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* Antibiotics may be prescribed
* Paralytic drugs |
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Positioning and Deep Breathing for airway maintenance
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* Turned, repositioned, OOB
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Surgical management for airway maintenance
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* Tracheostomy long term intubation
* Chest tubes to reexpand lungs |
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Acute/Chronic Pain
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* From burns and treatments
* Pain assessment scales * Medications * Diversional/alternative pain modalities * Important to alleviate/monitor pain * One of the MAJOR issues! |
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Drug Therapy for acute/chronic pain
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* 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 |
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Complementary and Alternative Tx for acute/chronic pain
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* Relaxation
* Focused breathing * Guided visual imagery * Music * Massage/therapeutic touch |
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Environmental Manipulation for acute/chronic pain
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* Quiet, restful, calm environment
* Increase patients control * Sleep deprivation * Plan care to provide rest/sleep * Tactile stimulation, may reduce pain * Changing position * Warm room temperatures * Patient involvement |
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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 |
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ARDS
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* 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 |
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Phases of Burn Injury
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- Emergency
- Acute phase - Rehabilitative phase |
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Emergency Phase
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* First 48 hours
* Maintain an open airway, ensure adequate breathing/circulation * Limit extent of injury/maintain function of vital organs * Prevent potential complications |
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Acute phase
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* First 48 hours to complete wound closure
* Maintenance of cardiovascular/respiratory systems * Nutritional status * Burn wound care * Pain control * Psychosocial interventions |
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Interventions for Burn Wound Management - nonsurgical
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- Debridement
- Dressings |
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Types of Debridement
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- Mechanical
- Enzymatic |
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Types of Dressings
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- Standard wound dressings
- Biologic dressings - Synthetic dressing/artificial skin |
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Interventions - surgical
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- Surgical excision
- Wound coverings |
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Surgical management
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* For contractures is restorative
* Most common in neck, axilla, elbow, hand * Improves movement * Postop care * Prevention of further contractures * Body Image Disturbance |
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Body Image Distrubance
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* Serious problem
* Nonsurgical management * Nursestages 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 patients feelings without internalizing * Assurance to patient feelings are normal Cont * May need to provide referral * Nurse must accept patients physical appearance * Work with family/groups |
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SURGICAL MANAGEMENT for body image
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- reconstructive surgery
* Cosmetic surgery * May be performed for many years * Restoration of function/appearance * Increases patients feelings of self-worth * Patients may have unrealistic expectations, education critical |
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Immune
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* Infection = LEADING CAUSE OF MORTALITY/MORBIDITY acute phase
* Nurse continually assess patient for s/sx infection * Gram+, gram -, fungal infections * METICULOUS HAND WASHING * Local and systemic s/sx infection |
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Burns-Nursing Diagnosis
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* Decreased cardiac output
* Deficient fluid volume * Ineffective tissue perfusion (multiple) * Ineffective breathing pattern * Pain * Excess fluid volume * Risk for ineffective thermoregulation * Sensory/perceptual alterations |
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Vesicles...which type of wound?
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Superficial partial thickness
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Red and waxy without vesicles...what type of wound?
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Deep partial thickness
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Black eschar?
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Deep full thickness
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Sunburn, example of?
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Superficial wound
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Nerve endings exposed?
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Deep superficial partial thickness
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