Burns-Ch 57

Front 1

Indicators of possible pulmonary damage include the following:

Back 1

History indicating that the burn occurred in an enclosed area
Burns of the face or neck
Singed nasal hair
Hoarseness, voice change, dry cough, stridor, sooty sputum
Sooty or bloody sputum
Labored breathing or tachypnea (rapid breathing) and other signs of reduced oxygen levels (hypoxemia)
Erythema and blistering of the oral or pharyngeal mucosa

Front 2

Consensus Formula

Back 2

Lactated Ringer's solution (or other balanced saline solution): 2–4 mL × kg body weight × % total body surface area (TBSA) burned. Half to be given in first 8 h; remaining half to be given over next 16 h.

Front 3

High risk populations;

Back 3

very young, very old, very poor. Those who live in manufactured homes or in rural areas

Front 4

Outlook for Survival and Recovery

Back 4

Outcome depends on the depth and extent of the burn as well as on the preinjury health status and age of the patient.

Front 5

Classification of Burns
based on

Back 5

Burn Depth
Extent of Body Surface Area Injured

Front 6

superficial partial-thickness burn:

Back 6

the epidermis is destroyed or injured and a portion of the dermis may be injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister

Front 7

deep partial-thickness burn:

Back 7

involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. Hair follicles remain intact. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars

Front 8

A full-thickness burn involves

Back 8

total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue. Wound color ranges widely from white to red, brown, or black. The burned area is painless because nerve fibers are destroyed. The wound appears leathery; hair follicles and sweat glands are destroyed

Front 9

Burn depth is determined by

Back 9

a. How the injury occurred
b. Causative agent, such as flame or scalding liquid
c. Temperature of the burning agent
d. Duration of contact with the agent
e. Thickness of the skin

Front 10

Palm Method;

Back 10

In patients with scattered burns, the palm method may be used to estimate the extent of the burns. The size of the patient's palm is approximately 1% of the TBSA.

Front 11

Cardiovascular Alterations

Back 11

i. Hypovolemia d/t fluid loss
ii. Burn shock face begins
iii. Prompt fluid resuscitation is needed to maintain blood pressure
iv. Anemia may occur d/t red blood cell injury

Front 12

Fluid and Electrolyte Alterations

Back 12

i. massive edema occurs with extensive burns
ii. edema may cause constriction of the blood vessels and results in ischemia
iii. hyponatremia occurs during the first week
iv. hyperkalemia results from massive cell destruction. Hypokalemia may occur later with fluid shifts and inadequate potassium replacement.

Front 13

Pulmonary Alterations

Back 13

i. Bronchoconstriction caused by release of histamine, serotonin, and thromboxane, a powerful vasoconstrictor.
ii. Treated by early intubation
iii. Expectoration of carbon particles in the sputum is the cardinal sign of inhalation injury below the glottis.
iv. Airway obstruction may occur very rapidly or develop in hours

Front 14

Renal Alterations

Back 14

i. may be altered as a result of decreased blood volume
ii. destruction of red blood cells causes blood in the urine
iii. hemoglobin and myoglobin destruction may occlude the renal tubules

Front 15

Thermoregulatory Alterations

Back 15

i. inability to regulate body temperature.
ii. exhibit low body temperatures in the early hours after injury
iii. the patient becomes hyperthermic for much of the postburn period.

Front 16

Gastrointestinal Alterations

Back 16

i. paralytic ileus
ii. Curling’s ulcer

Front 17

Emergent/Resuscitative Phase
i. On-the-Scene Care From onset of injury to completion of fluid resuscitation

Back 17

a. Prevent injury to the rescuer
b. cool the wound
c. establish an airway
d. supply oxygen
e. insert at least one large-bore IV line

Front 18

Emergent/Resuscitative Phase
ii. Medical Management

Back 18

a. ABC’s
b. IV resuscitation
c. G- tube if the burn is over 20-25% TBSA
d. IV meds for pain ie Morphine

Front 19

Emergent/Resuscitative Phase
Transfer to Burn Center

Back 19

a. major burns, those who are at the extremes of the age continuum, those with coexisting health problems that may affect recovery, and those with circumstances that increase their risk for acute and long-term complications are transferred to a burn center

Front 20

Emergent/Resuscitative Phase
Management of fluid loss and shock

Back 20

a. Next to managing respiratory difficulties, the most urgent need is preventing irreversible shock by replacing lost fluids and electrolytes. As stated previously, survival of the patient with burn injury depends on adequate fluid resuscitation
b. Fluid Replacement Therapy

Front 21

Parkland/Baxter Formula

Back 21

Lactated Ringer's solution: 4 mL × kg body weight × % TBSA burned
Day 1: Half to be given in first 8 h; half to be given over next 16 h
Day 2: Varies. Colloid is added.
v. Hypertonic Saline Solution
Concentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250–300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output. Do not increase the infusion rate during the first 8 postburn hours. Serum sodium levels must be monitored closely. Goal: Increase serum sodium level and osmolality to reduce edema and prevent pulmonary complications

Front 22

Nursing Management

Back 22

a. Maintenance of adequate tissue oxygenation
b. Maintain patent airway and adequate airway clearance
c. Restoration of optimal fluid and electrolyte balance and perfusion of vital organs
d. Maintenance of adequate body temperature
e. Control of pain
f. Minimization of patient's and family's anxiety
g. Absence of complications

Front 23

Acute/Intermediate Phase-

Back 23

The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury

Front 24

Acute/Intermediate Phase-
interventions

Back 24

i. Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to the intravascular compartment, losses of fluid from large burn wounds, and the patient's physiologic responses to the burn injury
ii. Infection Prevention
iii. Wound Cleaning
iv. Topical Antibacterial Therapy

Front 25

Wound Débridement
Goals

Back 25

i.To remove tissue contaminated by bacteria and foreign bodies, thereby protecting the patient from invasion of bacteria
ii. To remove devitalized tissue or burn eschar in preparation for grafting and wound healing

Front 26

Natural Débridement

Back 26

i. the dead tissue separates from the underlying viable tissue spontaneously

Front 27

Mechanical Débridement

Back 27

involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar

Front 28

Surgical Debridement

Back 28

i. Early surgical excision to remove devitalized tissue along with early burn wound closure is now recognized as one of the most important factors ontributing to survival in a patient with a major burn injury

Front 29

Homografts

Back 29

are skin obtained from living or recently deceased

Front 30

Heterografts

Back 30

consist of skin taken from animals (usually pigs).

Front 31

Biologic Dressings (Homografts and Heterografts)

Back 31

i. Biologic dressings have several uses. In extensive burns, they save lives by providing temporary wound coverage and protecting the granulation tissue until autografting is possible.

Front 32

Biosynthetic and Synthetic Dressings

Back 32

composed of a nylon, Silastic membrane combined with a collagen derivative. The material is semitransparent and sterile

Front 33

Artificial skin (Integra) is the newest type of dermal substitute.

Back 33

A dermal analogue, Integra is composed of two main layers. The epidermal layer, consisting of silicone, acts as a bacterial barrier and prevents water loss from the dermis.

Front 34

Alloderm

Back 34

It is processed dermis from human cadaver skin, which can be used as the dermal layer for skin grafts

Front 35

Care of the graft

Back 35

i. Occlusive dressings
ii. splints to immobilize newly grafted areas to prevent dislodging
iii. dressing change is usually performed 2 to 5 days after surgery
iv. sterile saline compresses help prevent drying of the graft until the physician reapplies it.
v. The patient begins exercising the grafted area 5 to 7 days after grafting.

Front 36

Autografts

Back 36

i. Autografts remain the preferred material for definitive burn wound closure after excision. Autografts are the ideal means of covering burn wounds, because the grafts are the patient's own skin and therefore are not rejected by the patient's immune system.

Front 37

Care of the Donor Site

Back 37

i. moist gauze dressing is applied at the time of surgery
ii. sites must remain clean, dry, and free from pressure.
iii. heal spontaneously within 7 to 14 days with proper care
iv. Patient may need additional pain management

Front 38

Nutritional Support

Back 38

i. Persistent hypermetabolism may last up to 1 year after burn injury.
ii. The most important of these interventions is to provide adequate nutrition and calories to decrease catabolism
iii. If the oral route is used, high-protein, high-calorie meals and supplements are given

Front 39

Indications for parenteral nutrition include

Back 39

weight loss greater than 10% of normal body weight, inadequate intake of enteral nutrition due to clinical status, prolonged wound exposure, and malnutrition or debilitated
condition before injury

Front 40

Scars

Back 40

a. Hypertrophic scarring can cause severe contracture across involved joints
b. Compression measures are instituted early in burn wound treatment
c. Ace wraps are used initially to help promote adequate circulation, but they can also be used as the first form of compression

Front 41

Keloids

Back 41

A large, heaped-up mass of scar tissue, a keloid, may develop and extend beyond the wound surface. Keloids tend to be found in people with darkly pigmented skin, tend to grow outside of wound margins, and are likely to recur after surgical excision.

Front 42

Failure to Heal

Back 42

a. A serum albumin level of less than 2 g/dL is usually a factor in impaired healing in the patient with burns.

Front 43

Contractures

Back 43

a. The burn wound tissue shortens because of the force exerted by
b. the fibroblasts and the flexion of muscles in natural wound healing.

Front 44

Rehabilitation Phase;

Back 44

begins after the burn occurs and may continue for years.

Front 45

Rehabilitation Phase;
Priorities

Back 45

a. Wound healing
b. psychosocial support
c. restoration of maximal functional activity

Front 46

Rehabilitation Phase;
Prevention of Hypertrophic Scarring

Back 46

a. pressure garments
b. massage
c. lubrication
d. exercise
e. splints
f. manual lymphatic drainage
g. injectable steroids