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76 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Zone of Coagulation
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-center portion
-site of greatest heat transfer -irreversible skin/cell death occurs -most severe damage |
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Zone of Stasis
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-Impaired circulation, pronounced inflammatory reaction can lead to blood flow cessation.
-potentially salvageable -can convert to full-thickness injury |
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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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Zone of Hyperemia
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-outer most zone, peripheral zone
-early spontaneous recovery -vasodilation & increased BF -minimal cell involvement |
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The Parkland Formula
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•4ml x TBSA (%) x body weight (kg);
•50% given in first eight hours from the time of the burn •25% given in next 8 hrs, 25% given during last 8 hrs End point: •Urine –adults: 0.5–1.0 ml/kg/hour •Note: in order to ensure accurate calculations subtract any fluid that has already been received from the amount that is required for the first eight hours. |
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Superficial
(1st Degree) |
–Burn only superficial epidermis
-reddish, swelling, blanching with pressure -mild discomfort/pain –Healing occurs in 3-6 days Ex. Sunburn and minor steam burns |
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Superficial partial-thickness
(2nd Degree) |
–destruction of epidermis and some dermis
-moist surface with vesicles -pink or red, blanches with pressure -VERY PAINFUL –Healing occurs in 10 days |
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Deep partial-thickness
(2nd Degree) |
-destruction of epidermis and most of dermis
-moist or dry -pale, mottled, pearly red -blanching decreased or prolonged -Less painful -healing takes 3-6 weeks |
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Full thickness
(3rd & 4th Degree) |
-destruction of epidermis, dermis & underlying subcutaneous tissue
-dry, waxy, white leathery (or black) -no blanching -thrombosed blood vessel -PAINLESS Patient is extremely susceptible to infections, F&E imbalances, alterations in thermoregulation, and metabolic disorders. |
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Minor Burn Injury
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–Second-degree burn of <15% total body surface area (TBSA) in adults or <10% of TBSA in children
–Third-degree burn of <2% TBSA not involving special care areas (eyes, ears, face, hands, feet, perineum, joints) –Excludes all patients with electrical injury, inhalation injury, or concurrent trauma and all poor-risk patients (eg. Extremes of age, intercurrent disease) |
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Moderate, Uncomplicated Burn Injury
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–Second-degree burns of 15-25% TBSA in adults or 10-20% in children
–Third-degree burns of < 10% TBSA not involving special care areas –Excludes electrical injury, inhalation injury, or concurrent trauma and all poor-risk patients (eg, extremes of age, intercurrent disease). |
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Major Burn Injury
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over 25% TBSA burned
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What are the criteria for referral to a burn center?
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-partial thickness >10%
-3rd degree in any age group -burns to face, hands, feet, genitalia -electrical -chemical -inhalation |
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What are the 4 categories of burns?
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Thermal
Radiation Electrical Chemical |
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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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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 |
GOALS:
-save life -minimize disability -prepare for definitive care for next 24-26 hrs -FIRST HOUR after injury is most crucial!! |
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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 |
GOALS:
-wound closure -prevent infection -daily inspection/cleaning of wound -pain management with IV OPIOIDS |
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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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Do burns cause vasodialation or constriction?How?
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vasoconstriction
catecholamine's are released from the SNS |
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What is another name for third spacing?
How long does it last? |
burn shock
until the capillary injures are repaired, usually first 12 hr, can continue to 36hr |
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What is third spacing?
What does it cause? |
vessels become more permeable...allows fluids and colloids to leak into surrounding tissues
hypovolemia decrease blood volume and BP |
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Burn Shock Patho
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-Burn injuries > 35% TBSA at risk
-HYPOVOLEMIC shock is first component 1) increased capillary permeability 2) 3rd space shifting = blisters & edema 3) edema occurs locally (burn) and systemically (unburned tissue) |
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Hemodynamics of Burn Shock
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- decreased contractility
- decreased C.O. - increased SVR - increased PVR (may lead to pulmonary edema) |
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Emergent Phase I:
Initial Evaluation |
Nature of injury
specific agents involved length of exposure time of injury client's age location & size (rule of 9's) type/amount of fluid administered Medications/Allergies Tetanus status Immunizations and health history |
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Emergent Phase I:
AIRWAY management |
1st priority = secure & protect airway
administer 100% oxygen observe continuously for s/s impaired oxygenation (agitation, anxiety, stridor, hoarseness, wheezing) *may require intubation b/c airway edema increases during first 24hrs facial burns: suspect inhalation injury enclosed space: suspect CO poisoning |
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Emergent Phase I:
RESPIRATORY management |
circumferential full-thickness burns to chest wall may require eshartomy.
intubated: increasing peak airway pressures non-intubated: rapid/shallow respirations, poor chest wall excursion, severe agitation, ABGs: decreased O2, increased CO2) |
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Emergent Phase I:
CIRCULATORY Management |
Parkland Formula (LR solution used)
IV access with 16G or larger EKG - especially with electrical burns I&O monitoring over or under resuscitation may result in wound conversion!! |
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Emergent Phase I:
RENAL management |
Foley for burns > 15-20%
U/O goal: 0.5-1ml/kg/hr electrical burns: 2ml/kg/hr |
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What two labs are you going to be worried about with someone who has a burn?
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K+ [hyperkalemia]
(due to cell injury releasing K+) Na+ [hyponatremia] (aldosterone increases --> third spacing) stress |
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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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Airway assessment in burn patient:
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very important to evaluate facial burns, inhalation exposure, singed nasal hairs, stridor, s/s of hypoxia
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Emergent Phase I:
GI management |
20% TBSA prone to paralytic ileus (NGT/OGT)
Curling stress ulcer development prophalxysis H2 blockers & sucralfate) |
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Emergent Phase I:
PAIN management |
IV opiates (fentanyl & morphine) titrated
benzodiazepines for anxiety (ativan) H1 blockers for itching (benadryl) **pain comes form 2 sources: 1) procedural 2) background (always present) |
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Emergent Phase I:
Extremity Pulse Assessment |
-edema formation may cause NV compromise
-frequent assessment of 6p's!!! -doppler best way to assess arterial pulses |
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Emergent or Resuscitative Phase
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•First 48 hours
•Patient is transported to emergency department. •Fluid resuscitation is begun. •Foley catheter is inserted. •Patients with burns exceeding 20-25% should have an NG tube inserted and placed to suction. •Patient is stabilized and condition is continually monitored. •Patients with electrical burns should have an ECG. •Address pain; only IV medication should be administered. •Psychosocial consideration and emotional support should be given to patient and family |
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Emergent Phase of Burn Injury
Goals of management include: |
–Secure airway
–Fluid replacement •Greatest initial threat is hypovolemic shock! Due to a massive shift of fluids out of the blood vessels and can begin as early as 20 mins post burn. –Prevent infection –Maintain body temperature –Provide emotional support |
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Curling’s Ulcer
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is an acutepeptic ulcerof the duodenumresulting as a complication from severe burns when reduced plasmavolume leads to sloughing of the gastric mucosa.
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Potention Complications / Collaborative Problems
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•Acute respiratory failure
•Distributive shock •Acute renal failure •Compartment syndrome •Paralytic ileus •Curling’s ulcer |
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Nutritional Support
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•Burn injuries produce profound metabolic abnormalities. Patients with burns have great nutritional needs related to stress response, hypermetabolism, and wound healing.
•Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization. •Nutritional support is based on patient’s preburn status and % of TBSA burned. •Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems. •If the oral route is used, high-protein, high-calorie meals and supplements are given. |
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Inhalation Injury
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*Major predictor of mortality in burn patients*
•A general principle to remember is that inhalation injury above the glottis is thermally produced, and injury below the glottis is usually chemically produced. |
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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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Pathophysiologic changes in infraglottic injury:
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impaired ciliary activity, inflammation, hypersecretion, edema, ulceration of airway mucosa, increased blood flow, spasm of bronchi, impaired immunne defense
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What are the pulmonary effects of burn injuries?
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-Inhalation above glottis
-Inhalation below glottis -CO poisoning -Cyanide poisoning |
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Cyanide poisoning
How is it treated? |
-Hydrogen cyanide produced by burning high nitrogen plastics such as polyurethane
-Dx difficult, suggestive if hx and: aninon gap, metabolic acidosis, not responsive to O2, SvO2 is elevated -testing for blood cyanide is possible: thiocyanate level -Sodium thiosulfate (150mg/kg) administered IV can enhance hepatic metabolism of cyandie by converting cyanide to thiocyanate; Sodium nitrate 5mg/kg can be used in severe cases |
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Carbon Monoxide poisoing
How is it treated? |
-CO binds to Hgb 200-250x > affinity than O2
-Carboxyhemoglobin levels 40-60% cause obtundation and loss of consciousness; levels of 15-40% cause varying levels; >60 fatal -admin 100% O2 via non-rebreather mask -reduce carboxyhemoglobin to <10% -half life of CO in blood is 4-5hrs for patients on room air -half life of CO in reduced to ~1hr for patients on 100% O2 -CO can be measured on ABG |
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How is heat loss reduced?
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-ambient room temp 28-30
-warmed IVF -forced air warmer |
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Why do burn patients lose heat?
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hypermetabolism, evaporative fluid loss, exposure
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List 6 signs/symptoms of hypermetabolism:
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hyperthermia, increased catabolism, increased O2 consumption, tachypnea, tachycardia, elevated catecholamine levels
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Mnemonic "AMPLE"
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Allergies
Medications Previous hx Last meal Events |
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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 do you look for in paralytic ileus?
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No bowel sounds
Nausea and vomiting Abdominal distention |
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When should feeding be started?
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enteral feeding within 24-48hrs post-injury, decreases muscle catabolism and may reduce bacterial translocation thru gut
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Acute Phase:
Provide fluid therapy for patients |
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:
adequate nutrition |
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:
Burn/wound care |
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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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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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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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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Assisting with pain management in burn patient. What are interventions you would take?
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Analgesics IV - no subq or IM b/c unknown rate of absorption
Teach distraction/relaxation techniques Teach use of guided imagery |
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Contractures
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A contracture scar is a permanent tightening of skin that may affect the underlying muscles and tendons and solimit mobility and possibly damage or degeneratethe underlying nerves. Contractures develop when normal elastic connective tissues are replaced with inelastic fibrous tissue. This makes the tissues resistant to stretching and prevents normal movement of the affected area. Physical Therapy, pressure garments and exercise may in many casesaid in controlling contracture burn scars. If these treatments do not control the effects of contracture scars, surgery may be required.
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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 |
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Preexisting conditions that might influence burn recovery
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age, chronic illness (diabetes, cardiac problems, etc), physical disabilities, disease, medications used routinely, and drug/alcohol abuse.
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3 Types of debridement used:
1) Mechanical 2) Chemical 3) Surgical |
1) use scissors/forceps to trim necrotic tissue.
-pt may be submerged in bath in order to loosen eschar. -wet-wet/wet-dry dressings used 2) topical application of proteolytic enzymes 3) esharotomy: cutting of necrotic tissue down to bleeding tissue so that it may regenerate. |
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Should bleeding occur in surgical debridement?
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yes, if not, procedure should continue until bleeding occurs
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Wound Treatment:
Open Method |
advantages:
-wound easily assessed -no dressings to limit ROM -Reduced risk for compromised circulation (due to dressing) disadvantages: -strict isolation (increased risk of infection) -possible increase in discomfort b/c wound is open to air currents -increased risk of hypothermia -wound desiccation |
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Wound Treatment:
Multiple Dressing Change Method |
advantages:
-greater ease of patient mobility -decreased risk of infection -increased adherence of topical antimicrobial to wound disadvantages: -increased time in changing dressings -inability to assess wound btwn dressing changes -increased cost for multiple dressings -increased risk of impaired circulation |
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Silver Sulfadiazine (Silvadene)
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-painless application
-broad spectrum -most commonly used -easy application -rare sensitivities disadvantages: SE leukopenia minimal penetration of eschar |
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Mafenie acetate (Sulfamylon)
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-penetrates eshar
-broad spectrum -easy application disadvantages: metabolic acidosis painful application frequent sensitivities painful application |
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Bacitracin
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-painless application
-non-irritating -transparent disadvantages: OPEN method required to prevent yeast overgrowth -no eschar penetration -no gram-negative or fungal coverage |
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Pure Silver (Acticoat)
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-painless application
-broad spectrum -rare sensitivity -less frequent dressing changes disadvantages: keep moist with sterile water not saline |
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How do burns effect the renal system?
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ARF can occur in as high as 38% of cases, hypovolemia, increased levels of catecholamines, angiotensin, aldosterone, and vasopressin as well as sepsis and myoglin can contribute
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How can catecholamine secretion be minimized?
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adequate pain control, thermoneurtral environment, prevention/treatment of infection
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Autograft
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only graft that provides permanent coverage of the wound.
patient's unburned skin is used. -thigh -back -abdomen care of donor site is equally as important as as burn!! |
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Hemograft (allograft)
TEMPORARY |
skin from another person
placed with shiny surface down -rejection occurs 2 weeks after its application |
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Heterograft (xenograft)
TEMPORARY |
animal/pig graft
removed or dissolved b/c lack of blood supply in 5-7 days |
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