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14 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Categories of burns |
Thermal Radiation Electrical Chemical |
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Tissue destruction results from: |
Coagulation Protein denaturation Ionization of cellular contents |
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Critical systems affected include |
Respiratory Integumentary Cardiovascular Renal GI Neurologic |
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Characteristics of 1st degree burn |
-superficial partial thickness (sunburn) - Leaves skin pink or red - dry -painful -slight edema |
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Characteristics of second degree burn |
-deep partial- thickness destruction of epidermis and upper layers of dermis - painful (sensitive to touch and cold air) -Appear read or white, weeps fluid, blisters present -Hair follicles intact (hair does not pull out easily) -Very edematous -blanching followed by capillary refill -heals without surgical intervention -usually does not scar |
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Characteristics of third degree burns |
-Full-thickness; involves total destruction of dermis and epidermis - skin can not regenerate - requires skin grafting - Underlying tissues (fat, fascia, tendon, bone) may be involved. - Wound appears dry and leathery as eschatology develops - painless |
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How to determine severity |
Determined by extent of surface area burned
Rule of nines (for adults): -head and neck 9% -upper extremities 9% each -lower extremities 18% each -front trunk 18% -back trunk 18% - perineal area 1%
Lund and Browder chart |
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Stages of burn care |
Stage 1: Emergent -Begins at time of injury -Concludes with the restoration of capillary permeability -typically reverses 48-72 hours following the injury -characterized by fluid shift from intravascular to interstitial and shock -focus of care is to preserve vital organ functioning Stage 2: Acute - Occurs from beginning of diuresis to near completion of wound closure - Is characterized by fluid shift from interstitial to intravascular Stage 3: Rehabilitation - Occurs from major wound closure to return to optimal level of physical and psychological adjustment (approx 5 years) - Is characterized by grafting and rehabilitation specific to client needs |
3 stages |
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Signs of inhalation burns |
- Singed nasal hairs - Circumoral Burns - Conjunctivitis - Sooty or bloody sputum - Hoarseness - Asymmetry of check movements with respiration’s and use of accessory muscles indicative of pneumonia - Rales, wheezing, and ronchi denoting smoke inhalation |
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Signs of inadequate hydration |
-restlessness - disorientation - decreased urinary volume and urinary sodium - increased urinary specific gravity |
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Topical antimicrobial agents |
Mafenide: - Usually uses with open method of wound care - Painful; Causes mild acidosis - Penetrates wound rapidly Silver sulfadiazine (Silvadene) - Usually used with open method of wound care - Used to avoid acid-base complications - Keeps eschar soft, making debridement easier -penetrates wounds slowly Nitrofurazone (Furacin) - Used to prevent infections -Interferes with bacterial enzymes - Allergic contact dermatitis - May see superinfections -Monitor for signs of infection |
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Nursing plans and interventions for the Emergent phase |
Efforts directed toward stabilization with ongoing assessment Assist with admission care -Extinguish source of burn ~Thermal: remove clothes Immerse burn in tepid water Apply sterile dressing ~Chemical: flush with water or Normal saline ~Electrical: separate client from electrical source -Provide an open airway; intubation May be necessary if laryngeal edema is a risk -Determine baseline data: vital signs, blood gases, weight -Administer tetanus toxoid -Initiate fluid & electrolytes: lactated ringer’s -Insert NG tube to prevent vomiting, abdominal distention, and gastric aspiration -Administer IV pain medication as prescribed Monitor hydration status -record urinary output hourly (normal range 30-100ml/hr) -maintain IV fluids titrated to keep urine output WNL - Accurately record I&O - Weigh daily - Observe for signs of inadequate hydration Monitor respiratory functioning - provide respiratory functioning - Suction ET or nasotracheal tube - Monitor ABGs -Observe for cyanosis, disorientation - Administer O2 - Encourage use of incentive spirometer, coughing, and deep breathing Provide wound care - Use strict aseptic technique - Perform debridement and dressing changes according to client condition - change dressings in minimum time; premeditate client, maintain sterile technique -maintain room temp above 90*F humidified & free of drafts - Monitor body temperature frequently; have hyperthermia blankets available Assess for paralytic lieus - absence of bowel sounds - nausea and vomiting - abdominal distention Assist with management of pain - Administer analgesics IV - Teach distraction and relaxation techniques - Teach use of guided imagery Assess for circulation compromise in burns that constrict body parts. Prepare client for escharotomy |
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Nursing plans and interventions for the acute phase |
Characterized by fluid shift from interstitial to intravascular (diuresis begins) Provide infection control -Maintain protective isolation of entire burn unit - Cover hair at all times - Wear masks during dressing changes - Use sterile technique for hydrotherapy, dressing changes, and debridement - Administer IV antibiotics if indicated - live plants and flowers prohibited Splint and position client to prevent contractures -avoid use of pillows in cases of neck burns Perform ROM exercises (painful) -Administer pain meds immediately prior to performing ROM exercises - Perform active ROM exercises for 3-5 minutes frequently during day -mobilize active ROM exercises when up and about Provide fluid therapy (May use colloids to keep fluid in vascular space) - Monitor serum chemistries at all times - Keep and IV site available; a saline lock is helpful - Maintain Strict I&O - Encourage oral intake of fluids Provide adequate nutrition - Provide high-calorie (up to 5000/day,) high-protein, High-carbohydrate diet - Give nutritional supplements via NG feeding at night of calorie intake is inadequate - Keep accurate calorie counts - Administer all medications with milk or juice - May require TPN - weigh daily Provide burn and wound care - Cleansing per agency routine (daily or up to 3x/day) in hydrotherapy or shower - Wet to dry dressing changes two to three times a day to remove necrotic tissue and debris - Apply silver sulfadiazine (Silvadene) or mafenide acetate (Sulfamylon) to burn as prescribed -cover (closed method) or leave open (open method,) according to agency policy or physician’s prescription - Prepare client for grafting when eschar has been removed - Prepare client for autografts (use of client’s own skin for grafting.) - Use heat lamp to donor site following graft to allow the area to reepithelialize. |
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Nursing plan and interventions for the rehabilitation phase |
Characterized by the absence of infection risk Ongoing discharge plan occurs Client may return home when the danger of infection has been eliminated High-protein fluids with vitamin supplements are recommended Pressure dressings such as Jobst garments may be worn continuously to prevent hypertrophic scarring and contractures |
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