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116 Cards in this Set
- Front
- Back
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As a nurse what is your role in burn patients
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promote safety legislation and teach prevention concepts
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Name 4 causes of burn injury
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heat chemicals electrical and radiation
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what are 4 major goals related to burns
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prevention life saving measures prevention of disfigurement and disability through individual care rehabilitation through reconstructive surgery and rehab
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This burn is on the outer part of skin (epidermis) and is frost bite or sunburn
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1st degree/superficial partial thickness
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the dermis and epidermis is damaged and there are blisters
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deep partial thickness
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scalds flashburn or contact would cause what burn
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2nd degree/deep partial thickness
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Dermis epidermis and hyperdermis has severe tissue distruction and feels numb
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full thickness/3rd degree from prolonged exposure to hot liquids chemical or electrical
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Name 3 symptoms from a superficial partial thickness burn
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tingling pain soothed by cooling hypersensitive(Hyperesthesia)
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Contains connective tissue with blood vessels nerve endings and hair follicles and what skin is involved
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dermis and epidermis
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Joes skin is red painful and exudes fluid blistering hypersensitivity sensitive to air
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deep partial thickness/2nd degree
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deep partial thickness
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Involve destruction of the epidermis and upper layer o the dermis and injury to the deep potions of the dermis
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hair follicles remain intact
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2nd degree/deep partial thickness
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what kind of burn is this where the epidermis dermis and fat is involved(fat nerve muscle tissue and organ)
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full thickness burn
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amy has shock no pain and red cell destruction
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full thickness
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Bob has a full thickness burn and when changing his dressing on his wound what does it look like
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charred dry pale white or leathery
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burn can be red white brown or black
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third degree
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In a burn injury what is the outer zone
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Zone of hyperemia
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compromised blood supply inflammation and tissue injury is what zone
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middle zone of stasis(slowing of blood flow)
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cellular death occurs here and most damage
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inner zone of coagulation and cell death occurs(like clot into a mass)
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burn depth determines wheather------ will occur
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epithelialization how-cause-temperature-duration of contact-thickness of skin
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Rules of nine helps to tell TBSA burned so what is the breakdown on the body
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18% anterior trunk 18% posterior trunk 9% head and neck 9% both arms 18% leg 18% leg perinium 1%
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The rule of nines in child is different in that
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the legs are 13.5 each
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The Lund Browder chart
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is more accurate
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billy has a scattered burn how would you measure it
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palm method and the patients palm is 1%TBSA
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what happens to the tissue in an electrical burn
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direct tissue to the nerve and vessels cause tissue anoxia and death along with coagulation necrosis occurs
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This is the worst burn and has nerovascular damage
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electrical- can be thermal and electrical is the clothing is burnt
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You are the nurse and just got a client that has had a electrical burn what should you be aware of
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an entrance and exit wound-fractures from falls or muscle contractions- can be cardiac standstill-release of myoglobin may cause ATN
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Burns are categorized as what
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thermal(electrical) radiation and chemical
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what type of response will joe most likely have if the TBSA is less than 25%
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local
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When there is more than 25% TBSA burned there is a systemic response what is released into the blood
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cytokines and other mediators
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what happens in an initial burn
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shock-fluid shifts causing tissue hypoperfusion(decreased blood flow thru organ) and organ hypofunction ( stop working or slow)
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Hypovalemia occurs in burn patients what is it
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loss of fluid and decrease perfusion and oxygen delivery
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Joe is burnt and continues to lose fluid what will you notice
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decreased vascular volume BPand CO
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Jill in showing signs of the onset of burn shock what is going on in her body
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SNS releases catocholamines vasoconstrcition and increased pulse
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greatest fluid loss includes when
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1st 24-36hrs
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The early signs of burn injury are
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thirst increased rr heart rate-decreased bowel-increased blood sugar-vasoconstriciton pale cool arms/legs decreased urine high specific gravity
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vascular permeabilty casues what
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edema decreased blood volume viscosity increases
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Vascular permeability
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characterizes the capacity of a blood vessel wall to pass through small molecules (ions water nutrients) or even whole cells (lymphocytes on their way to the site of inflammation). Blood vessel walls are lined by a single layer of endothelial cells. The gaps between endothelial cells (cell junctions) are strictly regulated depending on the type and physiological state of the tissue.
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As edema increases
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skin becomes taut and it begins to act as a tourniquet- pressure on small blood vessels an nerves causing obstruction of blood flow and consequent ischemia (similar to compartment syndrome) leading to escharotomy
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Usually present and is common during the first week of the acute phase
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as water shifts from interstitial space to the vascular space
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Immediately after burn injury
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Hyperkalemia results from massive cell destruction
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what causes brochoconstriction
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release of histamine serotonin and thromboxane
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Name 4 categories of pulmonary injury
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upper airway( edema/direct heat) inhalation below glottis(noxious gases) carbon dixoide poison restrictive defects (edema around neck)
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what are some indicators for pulmonary damage
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burn was enclosed in area/singed nasal hair/on face and neck/stridor hoarse dry cough voice change/sooth or bloody sputum/tachypnea/hypoxemia/blistering or red of oral mucosa
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Hemoglobinuria
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Destruction of RBCs at the injury site results in free hemoglobin in the urine
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Myoglobinuria
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If muscle damage occurs myoglobin is excreted by the kidneys
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The Immune system is altered in a burn patient give a summary of this
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can lead to sepsis with a decrease in t cell immoglobulins and neutrophil function--in thermal burns sepsis is the leading cause--loss of skin is a factor in the problem
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Thermoregulatory functions
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As hypermetabolism resets the core temperature the patient becomes hyperthermic in the postburn period
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Adynamic ileus
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Due to massive trauma and potassium shifts
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Curlings Ulcer
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Gastric bleeding secondary to massive physiological stress
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Kyle has just arrived at the ER and was struck by lightening what is important to keep in mind
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treat as potential cervical spine injury
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Emergent Phase of burn patient
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from burn onset-5days/24-48hrs/fluid loss and edema/Continues until fluid mobilization and diuresis begin/fluid and electrolyte shift
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How would you manage fluid loss and shock
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BP above 100 systolic/Output of 30-50 hr/ pulse less than 110 /normal sodium/hemoglobin and hemocrit / and total output
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what causes brochoconstriction
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release of histamine serotonin and thromboxane
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Joe has just come out of a house fire what should you do for care (prehospital)
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prevent/stop injury/ABCs/start oxygen and large bore IV/remove restrictive items and cover wound/assess
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What is the biggest danger in emergent resuscitative phase
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hypovolemic shock
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what are the different types of fluid shifts in the emergent phase
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dehydration/hemoconcentration/hyperkalemia/hyponatremia/metabolic acidosis
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Name 4 categories of pulmonary injury
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upper airway( edema/direct heat) inhalation below glottis(noxious gases) carbon dixoide poison restrictive defects (edema around neck)
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The Immune system is altered in a burn patient give a summary of this
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can lead to sepsis with a decrease in t cell immoglobulins and neutrophil function--in thermal burns sepsis is the leading cause--loss of skin is a factor in the problem
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Emergent Phase of burn patient
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from burn onset-5days/24-48hrs/fluid loss and edema/Continues until fluid mobilization and diuresis begin/fluid and electrolyte shift
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Medical management for you as the nurse in the emergent resuscitative phase
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fluids-foley cath-NG tube if TBSA is over 20%=monitor and keep stable-ECG-ONLY IV PAIN MEDS- emotional support
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How would you manage fluid loss and shock
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BP above 100 systolic/Output of 30-50 hr/ pulse less than 110 /normal sodium/hemoglobin and hemocrit / and total output
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what are the different types of fluid shifts in the emergent phase
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dehydration/hemoconcentration/hyperkalemia/hyponatremia/metabolic acidosis
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what causes brochoconstriction
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release of histamine serotonin and thromboxane
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Name 4 categories of pulmonary injury
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upper airway( edema/direct heat) inhalation below glottis(noxious gases) carbon dixoide poison restrictive defects (edema around neck)
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what are some indicators for pulmonary damage
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burn was enclosed in area/singed nasal hair/on face and neck/stridor hoarse dry cough voice change/sooth or bloody sputum/tachypnea/hypoxemia/blistering or red of oral mucosa
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When the renal function is interrupted what is the cause
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decrease in CO
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Hemoglobinuria
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Destruction of RBCs at the injury site results in free hemoglobin in the urine
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Joe has just come out of a house fire what should you do for care (prehospital)
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prevent/stop injury/ABCs/start oxygen and large bore IV/remove restrictive items and cover wound/assess
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Kyle has just arrived at the ER and was struck by lightening what is important to keep in mind
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treat as potential cervical spine injury
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Emergent Phase of burn patient
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from burn onset-5days/24-48hrs/fluid loss and edema/Continues until fluid mobilization and diuresis begin/fluid and electrolyte shift
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What is the biggest danger in emergent resuscitative phase
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hypovolemic shock
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Medical management for you as the nurse in the emergent resuscitative phase
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fluids-foley cath-NG tube if TBSA is over 20%=monitor and keep stable-ECG-ONLY IV PAIN MEDS- emotional support
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How would you manage fluid loss and shock
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BP above 100 systolic/Output of 30-50 hr/ pulse less than 110 /normal sodium/hemoglobin and hemocrit / and total output
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what are the different types of fluid shifts in the emergent phase
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dehydration/hemoconcentration/hyperkalemia/hyponatremia/metabolic acidosis
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acute intermmediate phase is when
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48-72 hrs after
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what is burn wound care in intermmediate phase
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hydrotherapy/Silvadene/Sulfamylon/dressing change/wound debridement/grafting
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In Acute phase hyponatremia can occur what happens
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sodium is lost with diuresis and due to dilution as fluid enters vascular space
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What happens in acute phase with hypokalemia
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potassium shifts from extracellular fluid into cells
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In the Acute intermmediate phase metabolic acidosis can occur what is it
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is a distrubance in the bodys acid base balance that results in excessive acidity of the blood
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hemodilution
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decreased concentration of cells ans solids in the blood resulting from gain of fluid and happens in intermmediate phase of burn patients
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For pain management in burn patients what is used
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IV during emergent and acute/morphine/Fentanyl/address anxiety sleep deprivation and use nonpharm measures
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What is when dead tissue separates from underlying tissue
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natural debridement
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use of sissors scaples forceps
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mechanical debridement
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surgical removal of dead tissue
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surgical debridement
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name 3 types of burn pain
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background or resting(24 hr) /procedural(during wound change) /breakthrough(med decrease to control background)
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what type of feeding tube is ideal in burn patient
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jejunal bc of lower risk of aspiration
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When does the rehab start
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as early as possible in the emergent phase and extends long after
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what would you focus on in rehab for the bburn patient
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self image-psycho social support-lifestyle-maximal functional abbilities-
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What is are complications in a burn patient with muscleskeletal
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low ROM and contractures
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what is third spacing
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loss of ECF into a space that does not contribute to equilibrium
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what are electroltyes
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active chemicals that carry positve and negative electrical charges
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What are the positive cations
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sodium potassium calcium mag hydrogen ions
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what are the negative anions
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chloride bicarbonate phosphate sulfate proteinate ions
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what is the major cation in ECF
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sodium
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What is the major cation in ICF
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potassium
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movement of fluid thru cappilary walls depends on
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hydrostatic and osmotic pressure
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this is pressure exerted on the walls of blood vessels
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hydrostatic pressure
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this is pressure exerted by the protein in the plasma
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osmotic pressure
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The direction of fluid movement depends on what
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diff of hydrostatic and osmotic pressure
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Osmosis
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movement of FLUID from lower solute to high solute concentration
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Diffusion
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movement of MOLECULES AND IONS from high to low concentration
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Filtration
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movement of WATER AND SOLUTES from high to low HYDROSTATIC PRESSURE
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What is active transport
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pump that moves fluid from low to high concentration/movement against gradient/the pump maintains the higher concentration of extrc sodium and intrc potassium
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How do you lose fluid
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kidney(urine) skin loss lungs gi tract
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Signs of Hypocalcemia
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Convulsions Arrhythmias Tetany Spasms and Stridor
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Three big signs of Hypocalcemia
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Tetany=numbess and tingling leading to spasms and convulsions/ Chvosteks sign=cheek twitiching/Trousseaus sign=carpal spasm of the hand when a BP cuff is inflated above sytolic pressure
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What is hyperKAlemia
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more than 5.5 of potassium/MURDER= muscle weakness urine(oliguria/aninuria)respiratory distress/decreased cardiac contractility/ECG changes(peaked Twave)/Reflexes are off
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How to treat hyperkalemia
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diuretics Kayexalate iv insulin with glucose iv calcium gluconate/moitor BS ECG lab values
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What is HypoKAlemia
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below 3.5 potassium
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GI losses can lower what especially
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potassium
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Signs of HypoKalemia
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leg cramps weakness polyuria flatTwaves weak pulse
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What to do with a patient with a hyperKalemia
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bannanas raisin green veggies bran cereal potaotoes dried beef/give potass Iv or oral
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when joe has been vomiting what is he at risk of having
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metabolic alkalosis which is a loss of acid
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What does a person normally take in and out
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in 3000 and out 1500 and the reason it is half that goes out because of other methods like breathig and sweat
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Hypovolemia
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loss of ECF fluid and may occur with other imbalances, rapid pulse,vasoconstriction, look at weight i/o mental status
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