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40 Cards in this Set
- Front
- Back
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Describe Burns.
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Tissue injury or necrosis caused by transfer of energy from a heat source to the body.
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What are the 4 categories of burns?
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Thermal
Radiation Electrical Chemical |
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Tissue destruction from burns results from what?
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Coagulation
Protein denaturation Ionization of cellular contents |
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What are the critical systems of the body that are affected by burns?
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Respiratory
Integumentary Cardiovascular Renal GI Neurological |
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Describe the severity of a 1st Degree Burn.
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Superficial partial-thickness burns (sunburn)
Leaves skin pink/red Dry Painful (relieved by cooling) Slight edema |
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Describe the severity of a second degree burn?
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Deep partial-thickness destruction of epidermis and upper layers of dermis
Injury to deeper portions of the dermis Painful (sensitive to touch and cold air) Appears red or white, weeps fluid, blisters Hair follicles remain intact Very edematous Blanching followed by capillary refill Heals without surgical intervention, usually does not scar |
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Describe the severity of a third degree burn?
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Full-thickness involves total destruction of dermis and epidermis
Skin cannot regenerate Requires skin grafting Underlying tissue (fat, fascia, tendon, bone) may be involved. Wound appears dry and leathery as eschar develops Painless |
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How do you determine the extent of a surface area burn?
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Use Rule of Nines
Lund and Browder chart |
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What are the % of the Rule of Nines?
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head and neck 9%
upper extremities 9 % each lower extremities 18% each front/back trunk 18% each 1% perineal area |
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There are three stages of burn care. Name them.
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Stage I - Emergent Phase
Stage II - Acute Phase Stage III - Rehabilitation Phase |
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Describe Stage I or the Emergent Care Phase.
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Begins at the time of injury and concludes with the restoration of capillary permeability, which typically reverses 48 to 72 hours following an injury.
Characterized by fluid shift from intravascular to interstitial and shock. Focus on care is to preserve vital organ functioning. Expect to administer large volumes of fluid in this face. |
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Describe Stage II or the Acute Care Phase
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Occurs from beginning of diuresis to the near completion of wound closure
Characterized by fluid shift from interstitial to intravascular |
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Describe Stage III or the Rehabilitation Phase
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Occurs from major wound closure to return to optimal level of physical and psychosocial adjustment (about 5 years)
Characterized by grafting and rehabilitation specific to the client's needs. |
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What are things you will assess for?
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Absence of bowel sounds
Radically decreased UO in 1st 72 hours with increased specific gravity Radically increased UO 72 hours to 2 weeks after initial injury Signs of inadequate hydration Signs of inhalation burn Description of physiological responses to burns Preexisting conditions/illness which could influence recovery |
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Why would you want to listen to bowel sounds?
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Paralytic Ileus
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What are the signs of inadequate hydration when you assess a burn patient?
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Restlessness
Disorientation Decreased urine output, urinary sodium, and increased specific gravity |
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What are signs of an inhalation burn?
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Singed nasal hairs
Circumoral burns Conjunctivitis Sooty or bloody sputum Hoarseness Asymmetry of chest movements with respirations and use of accessory muscles indicate pneumonia Rales, wheezing, and rhonchi denoting smoke inhalation |
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Nursing interventions with burns are directed towards...
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Stabilization with ongoing assessment
Provide admission care Monitor hydration status Monitor respiratory functioning Provide wound care Assess for paralytic eleus Assist with pain management Assess for circulatory compromise in burns that constrict body parts. |
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Thermal burns. How to you remove the source of the burn?
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Remove clothing
Cool burns by immersion in tepid water Apply dry sterile dressing |
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Chemical burns. How do you remove the source of the burn?
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Flush with water or saline
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Electric burn. How do you remove the source of the burn?
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Separate client from electrical source
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After removal of the source of the burn what are steps you want to do?
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Provide an open airway (intubation, esp if laryngeal edema)
Determine baseline data: VS, blood gases, weight Determine depth and extent of burn Administer tetanus toxoid Start F& E therapy Insert NG to prevent vomiting, abdominal distention, or gastric aspiration Administer IV pain medication as prescribed |
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Why do you give tetanus toxoid?
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Tetanus Toxoid is used to prevent tetanus (also known as lockjaw).
Tetanus is a serious illness that causes convulsions (seizures) and severe muscle spasms that can be strong enough to cause bone fractures of the spine. |
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What are the measures do you take when monitoring fluid hydration?
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Record UO (30-100 mL/hour)
Increase IV fluids to keep UO normal flow Weigh patient S/S inadequate hydration: restlessness, disorientation, hypothermia, decreased UO |
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What are the measures do you take when monitoring respiratory functioning?
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Provide care for intubation
Suction Monitor ABGs Observe for cyanosis, disorientation Administer O2 Encourage use of incentive spirometer, coughing, and deep breathing |
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What are the measures do you take when providing wound care?
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Use aspeptic technique
Debridement and dressings changes according to client's condition. Change dressings in minimum time, premedicate (painful!) Maintain room temperature above 90 'F, humidified, free of drafts Monitor body temperature frequently; have hyperthermia blankets available |
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HES HINT: Infection and Burns
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Infection is a life-threatening risk for those with burns.
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What do you look for in paralytic ileus?
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No bowel sounds
Nausea and vomiting Abdominal distention |
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Assisting with pain management in burn patient. What are interventions you would take?
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Analgesics IV
Teach distraction/relaxation techniques Teach use of guided imagery |
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How do you know that the patient is in the acute phase of burn injury?
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Fluid shifts from interstitial to intravascular space (diuresis begins)
Occurs from 72 hours to two weeks after initial injury to near completion of wound closure |
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What are the nursing interventions you want to provide during the acute phase of a burn?
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Infection control
Splint client to prevent contractures. Avoid use of pillows with neck burns. Perform ROM. It is very painful, though. Provide fluid therapy; colloids to keep fluid in vascular space. Provide adequate nutrition. |
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Infection control and burns
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Maintain protective isolation of entire burn unit
Cover hair at all times Wear masks during dressing changes Use sterile technique for hydrotherapy, dressing change, and debridement Live plants and flowers are prohibited |
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Acute Phase of Burns: Performing ROM. What do you do?
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Give pain meds before you start ROM.
Perform ROM 3-5 minutes frequently during the day. Mobilize as soon as possible using splints for the client. Encourage active ROM when up and about. |
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Acute Phase of Burns: Provide fluid therapy for patients
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Use colloids to keep fluid in the intravascular space
Monitor serum chemistries at all times Keep an IV site available; a heparin lock is helpful Maintain strict I&O Encourage oral intake of fluids |
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Acute Phase of Burns: adequate nutrition
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High-calorie (up to 5000 calories/day)
High-protein High-carbohydrate Give supplements via NG tube feeding at night if caloric intake is inadequate Keep accurate calorie counts Administer all medications with either milk or juice Weigh daily |
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Acute Phase of Burns: Provide burn/wound care
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Cleansing per your agency routine (daily or up to TID)
Wet to dry dressing changes two or three times daily to remove eschar Apply silver sulfadiazine (Silvadene) ormafenite acetate (Sulfamylon) to burn Closed/Open Method - according to your agency policy Prepare client for grafting when eschar has been removed Prepare client for autograpfts (usng own skin) Use heat lamp to donor site following graft to allow the area to reepithelize |
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HESI HINT: Pre-existing conditions
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Preexisting conditions that might influence burn recovery are age, chronic illness (diabetes, cardiac problems, etc), physical disabilities, disease, medications used routinely, and drug/alcohol abuse.
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Mafenie acetate (Sulfamylon)
Is a topical anitmicrobial agent What is it indicated for? What is the nx implication? |
Treatment of burns
Usually used in OPEN method of wound care Pain meds PRIOR to dressing changes Penetrates wound rapidly |
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Silver Sulfadiazine (Silvadene)
Is a topical anitmicrobial agent What is it indicated for? What is the nx implication? |
Treatment of burns
Usually used in OPEN method of wound care Used to avoid acid-base complications Keeps eschar soft, making debridement easier |
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Rehabilization phase is characterized by...
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absence of infection risk
ongoing discharge planning May return home when the danger of infection has been eliminated High-protein fluids with vitamin supplement Pressure dressings such as Jobst garments may be worn continuously to prevent hypertrophic scaring and contractures |
