CC Burns

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CC Burns
2015-04-03 18:31:06
lccc nursing complexcare burns

For Gordon's Exam 3
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  1. What are the different mechanisms of burns? Who are the most vulnerable populations?
    • Heat: flames, scolding water
    • Chemicals: battery acid, cleaning fluid
    • Radiation: sun, equipment
    • Inhalation: smoke
    • Vulnerable populations include children and the elderly
  2. What is the function of the integumentary system?
    • Intact skin protects from infection
    • Prevention of loss of bodily fluids
    • Thermoregulation
    • Production of vit D
    • Excretion (sweat)
    • Sensation reception
  3. What determines the severity of a thermal burn?
    • Duration of contact
    • Temperature of agent
    • Amount of tissue exposed
    • Age of patient
  4. What is the method of injury for a chemical burn?
    • Contact
    • Inhalation or fumes
    • Ingestion or injection
    • *can have both local and systemic effects and must be  completely neutralized or damage continues
  5. What determines the severity of a chemical burn?  What are some basic interventions that can be done?
    • Severity determined by:
    • type of agents
    • volume of agent
    • duration of contact
    • concentration of agent
    • Alkaline vs. Acid

    basic interventions- remove chemical (if dry, simply brush off do not wet!) and remove clothing. Call poison control asap
  6. Describe how electrical injuries are effected by the level and type of electricity
    • High voltage is >1000 wats, low voltage is <1000wats
    • Alternating Current (AC): flow of electrical charge periodically reverses direction. higher probability of cardiac arrest
    • Direct Current (DC): unidirectional flow of electrical charge. Damage from batteries, electric machines
  7. What factors contribute to the severity of an electrical burn?
    • Type and path of current (look for entry and exit wounds (exit is worse), always get EKG)
    • Duration of contact
    • Environmental factors (wet?)
    • Tissue resistance
  8. What are radiation burns and what factors contribute to the severity?
    • Exposure to large amounts of radioactive material
    • Severity:
    • type of radiation
    • distance from source
    • duration of exposure
    • absorbed dose
    • depth of penetration
  9. What is inhalation injury? What should be assessed? What is the greatest concern?
    • Such as carbon monoxide, smoke, bleach fumes
    • Assess for above the glottis and below the glottis injuries
    • Soot in note, throat can cause obstruction
    • Edema in airway can cause obstruction
  10. What is the immediate, general emergency management for burns?
    • Assess airway patency
    • Administer oxygen
    • Cover with blanket (prevent heat loss)
    • Keep NPO
    • Elevate the extremities if no fractures are obvious
    • Vital signs
    • Initiate 2 large bore IVs for fluid replacement
    • Administer tetanus shot
    • Head to toe assessment
  11. What emergency actions should be taken for thermal burns?
    • Smother the burns
    • Remove smoldering clothing and all metal objects
  12. What emergency actions should be taken for chemical burns?
    • If dry chemicals are present on the skin, brush them off (do not wet them!!)
    • Remove clothing
    • Determine the chemical causing the burn
    • Do no attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available
  13. What emergency actions should be taken for electric burns?
    • At the scene, separate patient from the electrical current
    • Smother any flames that are present
    • Initiate cardiopulmonary resuscitation
    • Obtain an ECG
  14. What emergency actions should be taken for radiation burns?
    • remove patient from radiation source
    • If the patient has been exposed to radiation from an unsealed source, remove the patient's clothing (using tongs or lead protected gloves)
    • If the patient has radioactive particles on their skin, send the patient to the nearest designated radiation decontamination center
    • Assist the patient in bathing or showering
  15. What factors should be taken into account when classifying the severity of a burn?
    • Type of burn
    • Burn wound characteristics
    • Other injuries
    • clients age
    • Preexisting health status
  16. Describe a superficial (first degree) burn
    • Epidermis only
    • Heals in 3-6 days without treatment
    • Erythema, blanching or pressure, pain and mild swelling
    • Not calculated for fluid resuscitation
  17. Describe a Partial thickness (Second degree) burn and what are the two categories?
    • Second degree burns involve both the epidermis and the dermis and blistering is common
    • Superficial partial thickness
    • Deep partial thickness
  18. Compare and contrast Superficial partial thickness burns with deep partial thickness burns
    • Superficial partial thickness is the epidermis and a portion of the dermis
    • Heals in 10-21 days
    • Moist, pink or mottled red, very painful due to exposed nerve ends blisters form
    • Deep partial thickness burns involve the epidermis and most of the dermis
    • Heal in 3-8 weeks
    • Pale, mottled, pearly red/white, less painful due to more nerve destruction
    • Scars form and grafts may aid in healing
    • BOTH may have blisters
    • BOTH are candidates for fluid resus
  19. Describe full thickness (3rd degree) burns
    • Destruction of all layers down to or past fat, fascia, muscle or bone (no hair or nerves)
    • Dry, thick leathery, black/brown, cherry red or white
    • No pain due to nerve destruction
    • Does not heal due to dermis destruction, requires grafting
  20. What are the different ways to determine the extent of injury? Describe the rule of 9s
    • Total body surface area perfect (TBSA%)
    • Patient's palm method
    • Lund-Brower chart
    • Rule of nines (different for adults and children)
  21. What are some assessments/interventions that should be taken depending on the location of the burn (head to toe)?
    • face, neck, chest: risk for resp obstruction
    • Hands, feet, joint: risk for self care deficits
    • ears, nose: risk for infection
    • Circumferential burns can cause compartment syndrome and need to be released with an escarotomy to prevent damage to vessels and nervses
    • * always assess CMS distal to burn site
  22. What are some pt risk factors that put a person at risk for a more severe burn/delayed healing/complicated healing?
    • Older adults heal slowly
    • Preexisting cardiovascular, respiratory, renal disease
    • DM
    • alcohol and drug abuse
    • Malnutrition
    • Concurrent fractures, head injuries or other trauma
  23. Describe the local response to a burn
    • Acute inflammation
    • Intravascular coagulation (hemoconcentration)
    • Altered vascular permeability (capillary leak syndrome)
    • *direct cell injury leads to release of potassium leads to immediate hyperkalemia, followed by hypokalemia, anemia (hemodilution) and hyponatremia during capillary leak
  24. What is a fluid shift? When does it occur? What E/F imbalances will be seen? What are s/s of burn shock?
    • Fluid shifts within 24 hours due to capilarry leak syndrome
    • Edema occurs in both burned and unburned areas for TBSA 20% or more
    • Maximum third spacing occurs 24-48 hours followed by diuretic phase
    • Burn shock- combination of distributive and hypovolemic shock (mixed shock with increased HR, decreased BP)
    • During fluid shift, hyponatremia, hypokalemia, and anemia (hemodilution) occurs
  25. What is the Parkland (Baxter) fluid resuscitation equation? what factors need to be considered?
    • Uses LR (crytalloid only solutions)
    • Fluid resus used for the first 24 hours AFTER burn (need to calculate from time of burn, not from time of arrival to ED)
    • Use the tule of 9's to get TBSA%
    • Fluid given by 2 large bore IVs or Central line
    • 1/2 of total fluid given during first 8 hrs, remainder given over 16 hrs
    • (for Gordon, round to 10th from the beginning of the equation!!)
  26. What is the cardiovascular response to burns? what about Pulmonary?
    • Cardiovascular:
    • -loss of intravascular volume
    • -decreased cardiac output
    • -tachycardia and vasoconstriction
    • Pulmonary:
    • -pulmonary hypertension
    • -effect of direct injury, such as pulmonary edema and obstruction (may lead to ARDS)
  27. What is the metabolic response to burns?
    • Hypermetabolic state may lead to a low grade fever
    • Increased caloric intake up to 5000 kcal/day, increased protein intake to aid in healing
    • Hypermetabolic state can last 9-12 months after burn
  28. Describe the GI response to burns
    • ischemia due to redistribution of blood to brain and heart
    • May result in a paralytic ileus
    • May result in a Curling's ulcer within 24hrs due to decreased blood flow to GI tract
  29. Describe the Renal response to burns
    • Sensitive to decreased cardiac output
    • Initial decrease in urine output related to decreased GFR and third spacing
    • Followed by diuresis as fluid shifts
  30. What are the 4 phases of burn management? describe prehospital care
    • Prehospital care, emergent (resuscitative), acute, rehabilitative
    • Prehospital care:
    • -remove the person from the source of the burn and stop the burning process
    • -caregiver needs to protect from becoming part of the incident (Safety assessment)
  31. What is the emergent phase? Describe the pathophys, s/s and possible complications
    • Emergent phase is the period of time required to resolve the immediate problems resulting from the burn injury
    • From the time of burn until 5+ days, but usually first 48 hrs
    • Phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begins
    • Pathophys includes F/E shifts, inflammation and healing, and immunologic changes
    • S/S include hypovolemic shock, shock from pain, blisters, adynamic ileus, shivering, altered mental status
    • Complications include cardiovascular, respiratory, urinary
  32. What nursing care should be done during the emergent phase?
    • Airway management: intubation, humidified/100% O2, escharotomy
    • Fluid Therapy: two large bore IVs or central line, Parkland (Baxter) formula for fluid replacement
    • Colloidal Therapy: D5W, Albumin
    • Wound care:: delayed until airway is secure, cleaning and debridement, may use immersion tank or shower, risk for infection is a serious threat. Open or closed method. May use allograft/homograft or xenograft
    • Other: manage self care deficits, routine lab tests, early ROM exercises
  33. What drug and nutritional therapy should be done during the emergent phase?
    • Analgesics and sedatives
    • Tetanus immunization
    • Antimicrobial Agents
    • Fluid replacement takes priority, oral intake not until bowel sounds return usually 48-72 hrs after injury
    • 5000 kcal/day
  34. What is the acute phase of a burn? Describe the pathophys, the s/s, and lab values
    • Acute phase begins with the mobilization of extracellular fluid and subsequent diuresis
    • Concluded when the burned area is completely covered by skin grafts r when the wounds are healed
    • Pathophys includes diuresis from fluid mobilization, return of BS, formation of granulation tissue and necrotic tissues sloughs
    • Partial thickness heals from the edges while full thickness is covered by skin grafts
    • S/S include necessary removal of eschar from partial thickness wounds (epithelization then occurs, 10-14 days) which full thickness burns will require debridement
    • Lab values to monitor include sodium (hyponatremia due to fluid shift) and potassium (hyperkalemia immediately followed by hypokalemia during cap leak)
    • Complications include infection, cardiovascular, respiratory, neuro, musculoskeletal, GI, and endocrine
  35. What nursing care should be done during the acute phase of a burn?
    • Wound care: daily assessments, cleansing, debridement
    • Excision and grafting: graft dressings, eschar removal, cultured epithelial autograft, artificial skin
    • Pain management: pharm and nonpharm
    • PT and OT: passive and active ROM, exercise during, after hydrotherapy. Prevents contractures
    • Nutritional: high calorie, supplements, daily weights
    • Psychosocial: social work, nursing staff, partoral care
  36. What is the rehabilitation phase of a burn? What is the pathophys and possible complications?
    • Begins when the patient's burn wounds are covered with skin or healed and the pt is able to resume a level of self-care activity
    • Pathophys includes wound healing wither by primary intention or grafting, layers of epithelization begin to rebuilding tissue structures, collagen fibers add strength to weakened areas, 4-6 areas are rained and mature healing occurs 6mo-2yr.  Skin never completely returns to orig color, pressure can prevent keloid scarring, newly healed areas can be hypo/hypersensitive, protect from direct sunlight for 1 yr
    • Complications include skin and joint contractures (PT and OT) and hypertrophic scaring
  37. What nursing care should be done during the rehabilitation phase of a burn?
    • Patient and family education on woundcare
    • Emollient based creams should not be used
    • Plastic surgery may be an option
    • Education on the importance of exercise
    • Continuous encouragement/reassurance
    • Address spiritual/cultural needs
    • High calorie, high protein diet
    • OT and PT
  38. What needs to be done for a burn patient prior to discharge?
    • Patient assessment
    • Financial assessment
    • Evaluation of family resources
    • Weekly meetings/followups
    • Psych referral
    • Patient and family learning (home care needs)
    • Development of a teaching plan for patient and family
    • Educating client and family on wound care
    • Rehab referrals
    • Home assessments for home care/accessibility needs
    • Medical equip/prosthetic needs
    • Evaluation of community resources
    • Re-entry programs for school or work
    • Auditory and speech therapy
  39. What emotional needs exists during a burn injury?
    • Family members need to understand the importance of reestablishing the pt's independence
    • Encourage family to participate as team members
    • Early psych intervention
    • Assess psycho-emotional cues
    • Common emotional response is regression
    • Issues of sexuality should be met with honesty
    • Family and patient support groups
  40. What are some expected patient outcomes for burn patients?
    • Cardiac output restored to normal
    • Pain alleviated or reduced
    • No further skin integrity lost and skin integrity restored
    • No infection
    • Adequate nutritional intake
    • Acceptable perception of body
  41. Describe some special nursing needs for burn unit nurses
    • Nurse cares for patients and family members who at times may be unpleasant, hostile, apprehensive and frustrated
    • Nurses new to burn unit often find it difficult to cope and need new coping skills