NSG 324

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NSG 324
2010-05-26 21:37:21

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  1. What are burns?
    • •Occurs when there is contact between tissue
    • and an energy source (heat, chemicals, electric, radiation)

    • •Results effected by intensity, duration of
    • exposure, type of tissue involved

    • •Burn prevention the responsibility of the
    • nurse
  2. Name the kinds of Thermal Burns?
    • - Flame ( Direct contact with Fire)
    • - Flash ( Brief contact with Fire)
    • - Scald ( contact with hot liquid)
    • - Contact ( with hot objects)
  3. How do you respond to chemical burns?
    • –lavaging area with copious
    • water/neutralizing agent

    • –possible tissue destruction up to
    • 72 hrs./respiratory complications
  4. What are the types of smoke and inhalation injuries?
    • 1.carbon monoxide poisoning
    • -elevated carboxyhemoglobin levels in victims trapped in
    • closed space
    • -treatment is 100% humidified oxygen
    • 2. inhalation injury above the glottis
    • -inhalation of hot air,steam, or smoke (thermally produced)
    • -Signs/Symptoms include singed nasal hairs, soot in nose/mouth, facial burns,mucosal burns of the naso/oropharynx
    • -may proceed to respiratory emergency ( due to mechanical obstruction)

    • 3. inhalation injury below the glottis
    • -usually chemically produced
    • - extent of injury depends on duration of the exposure
    • -clinical manifestations may not appear until 12-24 hrs after injury, and they manifest as ARDS
  5. What happens during a electrical burn?
    • –coagulation, necrosis of tissue, and direct damage to nerves
    • and vessels.

    –severity depends on amount of voltage, tissue resistance, current pathways, surface area in contact with current, length of exposure

    • –suspect long bone fractures from falls or tetanic muscle contractions (potential
    • cervical spine injury).

    –at risk for cardiac arrest, arrhythmias, metabolic acidosis, myoglobinuria (can lead to acute tubular necrosis-infuse Lactated Ringer to maintain urine output at 75-100cc/hr./possible addition of mannitol)
  6. How are burns classified?
    • 1. Depth
    • - partial thickness ( 1st and 2nd degree burns)
    • - full thickness (3rd and 4th degree burns)
    • 2. Extent
    • - Lund-Browder chart ( more accurate)
    • - Rule of nines
    • - Palmer surface area (eqautes to 1% of tbsa and used for irregular shaped burns)
    • 3. Location
    • - Burns to the face, neck, and circumferential chest/back can inhibit respiratory function
    • - Burns to the hand, feet, joints, and eyes make self care very difficult
    • - Burns to ears and nose are highly susceptible to infection

    • 4. Patient Risk Factors
    • - Age
    • - Comorbidities
  7. What happens during the emergent phase?
    –from burn onset until 5 or more days (usually 24-48 hrs.)…begins with fluid loss and edema formation and continues until fluid mobilization and diuresis

    –fluid and electrolyte shift (hypovolemic shock is greatest initial threat) second spacing and third spacing of fluids as well as hemolysis of RBC’s

    –immunologic changes-widespread impairment of the immune system…more susceptible to infection

    –clinical manifestations-pain with partial thickness, shock (hypovolemia)

    • –complications-cardiovascular syytem (escharotomies for circumferential injuries);
    • respiratory system-upper respiratory tract injury/inhalation injury; renal system-ATN (acute tubular necrosis)
  8. What nursing and collaborative care is done during the emergent phase?
    • •airway management- early nasotracheal or endotracheal intubation before compromise, fiberoptic bronchoscopy to assess lower airway, administration of
    • 100% O2, placed in Hi Fowlers position, encouraged DB&C, PEEP, hyperbaic oxygen

    •fluid therapy- 1 or 2 large bore catheters placed, IV fluids in burns >20%TBSA , accomplished with crystalloid or colloid solutions…usually Parkland Formula :4ml LR per kg body weight x TBSA for first 24 hrs. (1/2-first 8 hrs, ¼- second 8 hrs., ¼ of total in last 8 hr). adequate fluid replacement is measured by adequate urine output (30-50cc. per hr.)

    • •wound care- cleansing and debridement done in tank,shower, bed, infection is most serious threat (further tissue injury/sepsis), open method- burn is covered with a opical
    • antibiotic and has no dressing…closed method-sterile gauze impregnated with or
    • laid over topical antibiotic-dressings changed 2-3 times/daily…allograft orhomograft used for wound closure

    •other care measures-no pillows for neck burns/ear burns, early ROM

    •drug therapy- analgesics(IV medications initially-due to paralytic ileus, poor IM absorption) morphine is choice drug for pain management, tetanus immunization, antimicrobial agents- topicals- silver sulfadiazine, mafenide (systemic sepsis is usual cause of death in major burns)

    •nutritional therapy- nasogastric tube inserted with large burns (paralytic ileus) to LIS for decompression, hypermetabolic response when ileus resolved- require additional calories to prevent malnutrition and delayed healing
  9. what occurs during the acute phase?
    • •begins with the mobilization of extracellular fluid and subsequent diuresis
    • and concludes when the burned area is completely covered or wound is healed

    • •full thickness wounds- dry and waxy white to dark brown and have no sensation (nerve destruction) (require surgical debridement and skin grafting), partial thickness wounds-
    • pink to cherry red, wet and shiny and painful and heal within 10-14 days

    •laboratory values- sodium (hyponatremia-usually), potassium (hyperkalemia)

    • •complications- infection-underlying tissue has a bacterial density
    • >10to the 5th, can have the conversion of wound depths into a deeper burn,
    • sepsis from gram negative organisms (Psuedomonas); ROM limited due to healing
    • contractures, delirium, diarrhea from supplemental feeds, constipation from
    • narcotics, Curling’s ulcer-(H2 blockers), stress diabetes
  10. Nursing management and collaboration during the acute phase?
    –fluid replacement- NS, LR, glucose and saline, packed RBC’s, fresh frozen plasma,

    –physical therapy- maintain optimal functioning, passive/active ROM during/after hydrotherapy, splint to functional position

    • –wound care- goals: cleanse and debride necrotic tissue/debris, minimize
    • further destruction to viable skin, promote wound epitheliazation or success of grafting, and promote patient comfort

    • –excision and grafting- early (those with stable cardiovascular systems after fluid resuscitation) removal of necrotic tissue followed by split-thickness autograft
    • skin, cultured epithelial autograft, artificial skin

    –pain management- narcotics adjusted to the patient’s needs and response, guided imagery, visualization

    • –nutritional therapy- goal is to minimize energy demands and provide adequate calories and protein to promote healing…burns>20%TBSA formula: 25kcal x
    • kg of body wt.) + (40kcal x %TBSA burn), encourage high protein, high calorie, high carbohydrate foods
  11. What occurs during the rehab phase?
    •begins when the burn wound is covered with skin or healed and the patient is capable of assuming some self-care activity, 2 weeks to 2 months after burn injury

    •goal-assist the patient in resuming a functional role in society and accomplish functional and cosmetic reconstruction

    •pathophysiologic changes- primary intention or grafting healing, scarring- discoloration and contour…pressure garments

    •complications-skin and joint contractures and hypertrophic scarring…positioning, splinting, and exercise to minimize complications

  12. what nurse management and collaborative care is done during the rehab phase?
    • •be sensitive and attuned to the patient’s feelings-allow ventilation…learn how to care for healing wounds…possibility for reconstructive surgery, the role of exercise and
    • physical therapy

    •nutritional therapy- high calorie, high protein diet

    •gerontologic considerations-more complications in the emergent and acute phases, prevention strategies are important

    • •emotional needs of the patient and family- reestablish satisfactory body image, should involve the family during hospitalization, injury may precipitate a psychiatric episode,
    • post traumatic stress also a potential factor-refer to professional for better outcome, open communication is important, sexuality may also be an issue

    •special needs of the nursing staff-providing pain during therapies, long hospitalizations produce strong bonds