A&C 3-Burns

what is the rehabilitation phase?

--The rehabilitation phase begins when -Wounds have healed -Patient is engaging in some level of self-care -This can occur as early as 2 weeks or as long as 7 to 8 months after the burn injury. -Goals for the patient now are to (1) work toward resuming a functional role in society and (2) rehabilitate from any functional and cosmetic postburn reconstructive surgery that might be necessary.

drug therapy: antimicrobial

--Topical agents -Silver sulfadiazine (Silvadene) -Mafenide acetate (Sulfamylon) --Systemic agents are not usually used in controlling burn flora -Initiated when diagnosis of invasive burn wound sepsis is made

Acute Phase Complications: infection

--Watch for signs and symptoms -Hypothermia or hyperthermia -Increased heart and respiratory rate -Decreased BP -Decreased urine output -Mild confusion, chills, malaise, and loss of appetite may be observed. -The WBC count will usually be between 10,000/μl (10 × 109/L) and 20,000/μl (20 × 109/L). Functional defects in the WBCs are noted, and the patient remains immunosuppressed for a period after the burn injury.

what is a contracture?

A contracture (an abnormal condition of a joint characterized by flexion and fixation) develops as a result of shortening of scar tissue in the flexor tissues of a joint.

what is intravascular volume depletion?

The net result of the fluid shifts and losses

what is an escharotomy?

(a scalpel or electrocautery incision through the full-thickness eschar) is frequently performed following transfer to a burn center to restore circulation to compromised extremities

what do we need to keep in mind when applying antimicrobial agents?

**no iv antibiotics till sepsis is dx -After the wound has been cleansed, topical antimicrobial agents may be applied and covered with a light dressing. -Systemic antibiotics are not routinely used to control burn wound flora because little or no blood supply to the burn eschar is available, and consequently, delivery of the antibiotic to the wound is limited. -In addition, the routine use of systemic antibiotics increases the chance of development of multiresistant organisms. -Some topical burn agents penetrate the eschar and inhibit bacterial invasion of the wound. -Silver-impregnated dressings (Acticoat, Silverlon, Aquacel Ag) can be left in place anywhere from 3 to 14 days and are used in many burn centers. Silver sulfadiazine (Silvadene, Flamazine) and mafenide acetate (Sulfamylon) creams are also used. -Sepsis remains a leading cause of death in the patient with major burns, which may lead to multiple organ dysfunction syndrome. Systemic antibiotic therapy is initiated when the diagnosis of sepsis is made, or when some other source of infection (e.g., pneumonia) is identified.

what else for wound care?

--Shower -Once-daily shower -Dressing change in morning and evening --Infection is most serious threat to further tissue injury -Source of infection is patient's own flora

Rehabilitation Phase: Complications?

--Skin and joint contractures -Most common complications during rehab phase. -Positioning, splinting, and exercise should be used to minimize contracture.

pathophysiology of emergent phase?

---Fluid and electrolyte shifts -Colloidal osmotic pressure decreases (exerted by proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that usually tends to pull water into the circulatory system) -As the capillary walls become more permeable, water, sodium, and later plasma proteins (especially albumin) move into interstitial spaces and other surrounding tissue. -More fluid shifting out of the vascular space into interstitial spaces (Second spacing/ edema)

Emergent Phase: Complications. Airway

---Respiratory system --Upper airway burns -Edema formation -Mechanical airway obstruction and asphyxia ---Lower airway ---Pneumonia --Pulmonary edema Side notes: -Upper airway distress may occur with or without smoke inhalation, and airway injury at either level may occur in the absence of burn injury to the skin. -The patient may require a fiberoptic bronchoscopy and carboxyhemoglobin blood levels to confirm a suspected inhalation injury. -Look in the prehospital notes to see if the patient was exposed to smoke or fumes. -Examine any sputum that the patient may produce for any carbon. -Watch for signs of impending respiratory distress, such as increased agitation, anxiety, restlessness, or a change in the rate or character of the patient's breathing as symptoms may not be present immediately.

Classification of Burn: Injury Location of Burn

---Severity of burn injury is determined by location of burn wound --Face, neck, chest → respiratory obstruction -Burns to the face and neck and circumferential burns to the chest/back may inhibit respiratory function because of mechanical obstruction secondary to edema or leathery, devitalized burn tissue (eschar). These burns may also signal the possibility of inhalation injury and respiratory mucosal damage. --Hands, feet, joints, eyes → self-care -Burns to the hands, feet, joints, and eyes are of concern because they make self-care very difficult and may jeopardize future function. -Burns to the hands and feet are challenging to manage because of superficial vascular and nerve supply systems that need to be protected while the burn wounds are healing. --Ears, nose, buttocks, perineum → infection -Burns to the ears and the nose are susceptible to infection because of poor blood supply to the cartilage. -Burns to the buttocks or perineum are highly susceptible to infection from urine or feces contamination.

Emergent PhaseNursing/Collaborative Management. Wound care

---Should be delayed until a patent airway, adequate circulation, and adequate fluid replacement have been established --Cleansing -Can be done in a cart shower, shower, or bed --Debridement -May need to be done in the OR -Loose necrotic skin is removed {Cleansing and gentle debridement, using scissors and forceps, can occur on a cart shower, a regular shower, or a patient bed/stretcher by you and appropriate personnel} {Extensive surgical debridement is performed in the operating room (OR). During debridement, necrotic skin is removed. Releasing escharotomies and fasciotomies are carried out in the emergent phase, usually in burn centers by burn physicians}

Classification of Burn: Injury Depth of Burn

---partial-thickness burn --Superficial burn (1st degree) -Involves the epidermis (erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters) (superficial damage with hyperemia, tactile and pain sensation intact) --Deep partial-thickness burn (2nd degree) -Involves the dermis (fluid, filled vesicles that are red, shiny, wet. severe pain caused by nerve injury. mild to mod edema) (epidermis and dermis involved in various depths- epithelial regeneration still viable) --Full-thickness burn (3rd and 4th) -Involves all skin elements, nerve endings, fat, muscle, bone (dry, waxy, white, leathery, or hard skin. visible thrombosed vessels. insensitivity to pain bc of nerve destruction. possible involvement of muscles, tendons, and bones) ( all skin elements and local nerve endings destroyed. coagulation necrosis present. surgical intervention needed for healing).

explain acute phase?

--Begins with the mobilization of extracellular fluid and subsequent diuresis --Concludes when -Partial thickness wounds are healed and/or -Full thickness burns are covered by skin grafts

Classification of Burn: Injury Depth of Burn

--Burns have been defined by degrees (first, second, third, and fourth) --ABA advocates categorizing burn according to depth of skin destruction -Partial-thickness burn -Full-thickness burn (If significant damage to the dermis occurs (e.g., a full-thickness burn), remaining skin cells are insufficient to regenerate new skin. A permanent, alternative source of skin then needs to be found)

what do we need to look for from smoke inhalation injuries?

--Carbon monoxide (CO) poisoning -Hypoxia and ultimately death when CO levels are 20% or greater -Treat with 100% humidified oxygen -CO poisoning may occur in the absence of burn injury to the skin

explain thermal burns?

--Caused by flame, flash, scald, or contact with hot objects --Most common type of burn injury -Severity of injury depends on -Temperature of burning agent -Duration of contact time

Acute Phase Nursing/Collaborative Management: Excision and grafting

--Cultured epithelial autographs (CEAs) -Grown from biopsies obtained from the patient's own skin -Used in patients with a large body surface burn area or those with limited skin for harvesting -This procedure is performed in suitable patients in some burn centers as soon as possible. -The specimens are sent to a commercial laboratory, where the biopsied keratinocytes are grown in a culture medium containing epidermal growth factor. After approximately 18 to 25 days, the keratinocytes have expanded up to 10,000 times and form sheets that can be used as skin grafts. -The cultured skin is returned to the burn center, where it is placed on the patient's excised burn wounds. -CEA grafts generally form a seamless, smooth replacement skin tissue. Problems related to CEA include a poor graft take due to thin epidermal skin graft loss during healing, infection, and contracture development.

Emergent Phase: Complications? cardiac

--Dysrhythmias and hypovolemic shock --Impaired circulation to extremities --If untreated: -Tissue ischemia -Paresthesias -Necrosis -Impaired microcirculation and ↑ viscosity → sludging

explain emergent phase?

--Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury --The emergent phase ends when fluid mobilization and diuresis begin. --Up to 72 hours --Primary concerns -Hypovolemic shock -Edema

Acute Phase: Nursing/Collaborative Management: Wound care

--Enzymatic debridement -Speeds up removal of dead tissue from healthy wound bed Side note: -Enzymatic debriders made of natural ingredients, such as collagen, may be used for the enzymatic debridement of burn wounds, which speeds up the removal of dead tissue from the healthy wound bed. -Wounds are cleansed with soap and water or normal saline-moistened gauze to gently remove the old antimicrobial agent and any loose necrotic tissue, scabs, or dried blood. During the debridement phase, cover the wound with topical antimicrobial creams (e.g., silver sulfadiazine, silver-impregnated dressings). -When the partial-thickness burn wounds have been fully debrided, a protective, coarse or fine-meshed, grease-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed.

pathophysiology of emergent phase?

--Greatest threat is hypovolemic shock -Caused by a massive shift of fluids out of blood vessels as a result of increased capillary permeability -can begin as early as 20 min after burn

nutritional therapy?

--Hypermetabolic state -Early, continuous enteral feeding promotes optimal conditions for wound healing -Supplemental vitamins and iron may be given -Resting metabolic expenditure may be increased by 50% to 100% above normal in patients with major burns. -Core temperature is elevated. Catecholamines, which stimulate catabolism and heat production, are increased. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. -Failure to supply adequate calories and protein leads to malnutrition and delayed healing. Calorie-containing nutritional supplements and milkshakes are often given because of the great need for calories. Protein powder can also be added to food and liquids. Supplemental vitamins may be given as early as the emergent phase, with iron supplements often started in the acute phase.

Emergent Phase: Immunologic changes

--Immune system is challenged when burn injury occurs -Skin barrier is destroyed (deals with infection) -Bone marrow is depressed (= less blood cells in your body) -Circulating levels of immune globulins are decreased (not making EPO)

Smoke Inhalation Injuries: Upper airway injury?

--Injury to mouth, oropharynx, and/or larynx (Mucosal burns of the oropharynx and larynx are manifested by redness, blistering, and edema) --Thermally produced (by hot air, steam, etc) --Hot air, steam, or smoke --Swelling may be massive and onset rapid -Eschar and edema may compromise breathing -Swelling from scald burns can be lethal *Mechanical obstruction can occur quickly, presenting a true medical emergency.

Smoke inhalation injury: Lower airway injury

--Injury to trachea, bronchioles, and alveoli --Injury is related to length of exposure to smoke or toxic fumes --Pulmonary edema may not appear until 12 to 24 hours after burn -Manifests as acute respiratory distress syndrome (ARDS)

what is important to know about fluid loss?

--Normal insensible loss: 30 to 50 mL/hr --Severely burned patient: 200 to 400 mL/hr --Net result of fluid shift is intravascular volume depletion -Edema -↓ Blood pressure -↑ Pulse

different methods?

--Open method -Burn is covered with topical antibiotic with no dressing over wound --Multiple dressing changes or closed method -Sterilized gauze dressings are laid over topical antibiotic -Dressings may be changed from every 12 to 24 hours to once every 14 days

what are electrical burn patients at risk for?

--Patients are at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria (The electric shock event can cause immediate cardiac standstill or ventricular fibrillation. Delayed cardiac dysrhythmias or arrest may also occur without warning during the first 24 hours after injury) --Myoglobin and hemoglobin from damaged RBCs travel to kidneys -Acute tubular necrosis (ATN) -Eventual acute kidney injury (breakdown of muscle)

other care measures?

--Perineum must be kept as clean and dry as possible -Indwelling catheter -Perineal care --Routine laboratory tests --Early ROM exercises (Physical therapy is begun immediately, sometimes during showering/dressing changes and before new dressings are applied. Early range-of-motion (ROM) exercises are necessary to facilitate mobilization of leaked fluid back into the vascular bed. Active and passive exercise of body parts also maintains function, prevents contractures, and reassures the patient that movement is still possible)

explain chemical burns?

--Result of contact with acids, alkalis, and organic compounds --Alkali burns are hard to manage because they cause protein hydrolysis and liquefaction (broken down amino acids- more acidic?) -Damage continues after alkali is neutralized (no H+ ion, more acidic?) --these substances are usually found in cleaners and fertilizers, etc.

Importance of Electrical burns

--Severity of injury can be difficult to assess, as most damage occurs beneath skin ("Iceberg effect") -Electrical current may cause muscle spasms strong enough to fracture bones

classification of burn injury?

--Severity of injury is determined by -Depth of burn -Extent of burn in percent of TBSA -Location of burn -Patient risk factors

explain fluid and electrolyte shifts more in depth?

-As the capillary walls become more permeable, water, sodium, and later plasma proteins (especially albumin) move into interstitial spaces and other surrounding tissue. The colloidal osmotic pressure decreases with progressive loss of protein from the vascular space. This results in more fluid shifting out of the vascular space into the interstitial spaces. (Fluid accumulation in the interstitium is termed second spacing.) -Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. Examples of third spacing in burn injury are exudate and blister formation, as well as edema in nonburned areas.

importance of assessment of electrical burns?

-As with inhalation injury, a rapid assessment of the patient with electrical injury must be performed. Transfer to a burn center is indicated. -Determination of electric current contact points and history of the injury may help determine the probable path of the current and potential areas of injury. -Contact with electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae. Another reason to suspect long bone or spinal fractures is a fall resulting from the electrical injury. For this reason, all patients with electrical burns should be considered at risk for a potential cervical spine injury. Cervical spine immobilization must be used during transport and subsequent diagnostic testing completed to rule out any injury. -Electrical injury puts the patient at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis (waste products of burn are acidic), and myoglobinuria, which can lead to acute renal tubular necrosis (ATN). -The electric shock event can cause immediate cardiac standstill or fibrillation. Delayed cardiac dysrhythmias or arrest may also occur without warning during the first 24 hours after injury. -Myoglobin from injured muscle tissue and hemoglobin from damaged red blood cells (RBCs) are released into the circulation whenever massive muscle and blood vessel damage occurs. The released myoglobin pigments are transported to the kidneys, where they can mechanically block the renal tubules because of their large size. This process can result in ATN and eventual acute renal failure if not appropriately treated.

conditions leading to burn shock?

-At the time of major burn injury, capillary permeability is increased. -All fluid components of the blood begin to leak into the interstitium, causing edema and a decreased blood volume. -The red blood cells and white blood cells do not leak. -Hematocrit increases, and the blood becomes more viscous. -The combination of decreased blood volume and increased viscosity produces increased peripheral resistance. -Burn shock, a type of hypovolemic shock, rapidly ensues, and if it is not corrected, death can result.

how do you wrap extremities?

-Burned legs may first be wrapped with elastic (e.g., tensor/Ace) bandages to assist with circulation to leg graft and donor sites before ambulation. -Burned arms can be wrapped with a layer of tubular elastic gauze (e.g. Tubigrip). This interim pressure prevents blister formation, promotes venous return, and decreases pain and itchiness.

Classification of Burn: Injury Location of Burn/ what can it cause?

-Circumferential burns of extremities can cause circulation problems distal to burn -Patients may also develop compartment syndrome

Acute Phase: Complications: Musculoskeletal

-Decreased ROM -Contractures -The musculoskeletal system is particularly prone to complications during the acute phase and the involvement of both the physical and occupational therapist is vitally important.22 -As the burns begin to heal and scar tissue forms, the skin is less supple and pliant. -ROM may be limited, and contractures can occur. -Because of pain, the patient will prefer to assume a flexed position for comfort. You should encourage the patient to stretch and move the burned body parts as much as possible. Splinting can be beneficial to prevent/reduce contracture formation.

Rehabilitation Phase: Pathophysiologic Changes

-Discoloration of scar fades with time (Scarring has two components: discoloration and contour. The discoloration of scars will fade somewhat with time. However, scar tissue tends to develop altered contours; that is, it is no longer flat or slightly raised but becomes elevated and enlarged above the original burned area) -Pressure can help keep scar flat (Burn care providers believe that pressure can eventually help keep a scar flat. Gentle pressure is maintained on the healed burn with custom-fitted pressure garments and clear, thermoplastic face masks. Pressure garments and masks should never be worn over unhealed wounds and are removed only for short periods while bathing) -Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch (Additionally, these newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch. Grafted areas are more likely to be hyposensitive until peripheral nerve regeneration occurs. Healed burn areas must be protected from direct sunlight for about 3 months to prevent hyperpigmentation and sunburn injury) -Healed areas must be protected from direct sunlight for 3 months -These garments are worn up to 24 hours a day for as long as 12 to 18 months. The patient typically experiences discomfort from itching where healing is occurring. Application of water-based moisturizers and use of oral antihistamines (e.g., hydroxyzine [Atarax]) help reduce the itching. Massage oil, silicone gel sheeting (e.g., Biodermis), gabapentin, and injectable steroids also may be helpful.

Acute Phase: Pathophysiology

-Diuresis from fluid mobilization occurs, and patient is less edematous -Bowel sounds return -Healing begins as WBCs surround burn wound and phagocytosis occurs -Necrotic tissue begins to slough -Granulation tissue forms -Partial-thickness burn wounds heal from edges and from dermal bed -Full-thickness burns must have eschar removed and skin grafts applied

explain donor site being harvested?

-Donor skin is taken from the patient for grafting by means of a dermatome, which removes a thin (14/1000 to 16/1000 inch) split-thickness layer of skin from an unburned site. -The donor skin can be meshed (usually ratio of 1.5:1) to allow for greater wound coverage, or it may be applied as an unmeshed sheet for a better cosmetic result when grafting the face, neck, and hands. The donor site now becomes a new open wound.

signs of carbon monoxide poisoning

-Dull headache. -Weakness. -Dizziness. -Nausea or vomiting. -Shortness of breath. -Confusion. -Blurred vision. -*Loss of consciousness. -*Cherry red lips

what are some reliable clues to an upper respiratory injury?

-Presence of facial burns -Singed nasal hair -Hoarseness, painful swallowing -Darkened oral and nasal membranes -Carbonaceous sputum -History of being burned in enclosed space -Clothing burns around chest and neck

Emergent Phase: Nursing/Collaborative Management. Airway

-Early endotracheal intubation (After intubation, the patient is placed on ventilatory support, and the delivered oxygen concentration is based on ABG values. Extubation may be indicated when the edema resolves, usually 3 to 6 days after burn injury, unless severe inhalation injury is involved) -Escharotomies of the chest wall (Escharotomies of the chest wall may be needed to relieve respiratory distress secondary to circumferential, full-thickness burns of the neck and trunk) -Fiberoptic bronchoscopy within 6 to 12 hours to assess lower airway -Humidified air and 100% oxygen (When intubation is not performed, treatment of inhalation injury includes administration of 100% humidified O2 as needed. Place the patient in a high Fowler's position, unless contraindicated (e.g., spinal injury), and encourage coughing and deep breathing every hour. Reposition the patient every 1 to 2 hours, and provide chest physiotherapy and suctioning as ordered)

Phases of Burn Management?

-Emergent (resuscitative) -Acute (wound healing) -Rehabilitative (restorative)

Acute Phase Nursing/Collaborative Management: Excision and grafting

-Eschar is removed down to subcutaneous tissue or fascia -Graft is placed on clean, viable tissue -Wound is covered with autograft -Donor skin is taken with a dermatome -Choice of dressings varies

Explain smoke inhalation injuries?

-From inhalation of hot air or noxious chemicals -Smoke and inhalation injuries from the inhalation of hot air or noxious chemicals can cause damage to respiratory tract (Redness and airway edema may result) -Major predictor of mortality in burn victims -Need to be treated quickly

Acute Phase Nursing/Collaborative Management: Physical and occupational therapy

-Good time for exercise is during wound cleaning when the skin is softer and bulky dressings are removed. -Passive and active ROM -Splints should be custom-fitted -Ensure that the patient with neck burns continues to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension. -Maintain the occupational therapy schedule for the wearing of custom-fitted splints, which are designed to keep joints in functional position. Examine the splints frequently to ensure an optimal fit, with no undue pressure that might lead to skin breakdown or nerve damage.

Acute Phase Complications: Neurologic

-Hallucinations -Delirium (Delirium is more acute at night and occurs more often in the older patient) -Variety of causes have been considered

what else should we consider with chemical burns?

-In addition to tissue damage, eyes can be injured if they are splashed with a chemical. -Acids can be found in many household cleaners and include hydrochloric, oxalic, and hydrofluoric acid. -Alkali burns can be more difficult to manage than acid burns because alkalis adhere to tissue, causing protein hydrolysis and liquefaction. Alkalis are found in oven and drain cleaners, fertilizers, and heavy industrial cleansers. -Organic compounds, including phenols and petroleum products, produce contact burns and systemic toxicity. Phenols are found in chemical disinfectants, and petroleum products include creosote and gasoline.

drug therapy: VTE prophylaxis?

-Low-molecular-weight heparin or low-dose unfractionated heparin is started -Those with high bleeding risk, VTE prophylaxis with sequential compression devices, or compression stockings recommended

Acute Phase Nursing/Collaborative Management: Nutritional therapy

-Meeting daily caloric requirements is crucial -Caloric needs should be calculated by dietitian -High-protein, high-carbohydrate foods -Favorite foods from home -Patients should be weighed regularly -When the wounds are still open, the burn patient is in a hypermetabolic and highly catabolic state. -The patient may benefit from an antioxidant protocol, which includes selenium, acetylcysteine, ascorbic acid, vitamin E, zinc, and a multivitamin. -If the patient is on a mechanical ventilator or is unable to consume adequate calories by mouth, a small-bore feeding tube is placed and enteral feedings are initiated. When the patient is extubated, a swallowing assessment should be performed by a speech pathologist before the oral feeding is commenced.

Emergent Phase Nursing/Collaborative Management: Drugs

-Morphine -Hydromorphone (Dilaudid) -Haloperidol (Haldol) antipsychotic, "mood stabilizer" -Lorazepam (Ativan) benzo -Midazolam (Versed) benzo, stronger and requires consent because conscious sedation --Early in the postburn period, IV pain medications should be given because: -Onset of action is fastest with this route. -GI function is slowed or impaired as the result of shock or paralytic ileus. -Intramuscular (IM) injections will not be absorbed adequately in burned or edematous areas, causing pooling of medications in the tissues. When fluid mobilization begins, the patient could be inadvertently overdosed from the interstitial accumulation of previous IM medications. --Reevaluate analgesic requirements as patients' needs may change and tolerance to medications may develop over time. Initially, opioids are the drug of choice for pain control. When given appropriately, these drugs should provide adequate pain management. --Sedative/hypnotics and antidepressant agents can also be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. --Analgesic requirements can vary tremendously from one patient to another. The extent and depth of burn may not correlate with pain intensity.

fluid shift and electrolyte shift? in regards to Na and K?

-Na+ rapidly moves to interstitial spaces and remains until edema formation ceases (not because of choice, since there is so much Na in interstitial space, water follows) -K+ shift develops because injured cells and hemolyzed RBCs release K+ into extracellular spaces (hyperkalemic)

Acute Phase: Complications: Gastro

-Paralytic ileus (can be caused by sepsis) -Diarrhea (may result from the use of enteral feedings or antibiotics) -Constipation (can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet) -Curling's ulcer (a type of gastroduodenal ulcer characterized by diffuse superficial lesions (including mucosal erosion). It is caused by a generalized stress response due to decreased blood flow to the GI tract) {{Aim to prevent Curling's ulcer by feeding the patient as soon as possible after the burn injury. Antacids, H2-histamine blockers (e.g., ranitidine [Zantac]), and proton pump inhibitors (e.g., esomeprazole [Nexium]) are used prophylactically to neutralize stomach acids and inhibit histamine and the stimulation of hydrochloric acid (HCl acid) secretion.}}

importance in regard to blood?

-RBCs are hemolyzed by a circulating factor released at time of burn (The circulatory status is also affected by hemolysis of RBCs from circulating factors (e.g., oxygen free radicals) released at the time of the burn, as well as by the direct insult of the burn injury) -Thrombosis (clotting) (Thrombosis in the capillaries of burned tissue causes an additional loss of circulating RBCs) -Elevated hematocrit-hemoconcentration (An elevated hematocrit is commonly caused by hemoconcentration resulting from fluid loss. After fluid balance has been restored, dilution causes the hematocrit levels to drop) (meaning there is no water, therefore an higher hemo concentration)

explain Covering Donor Site With Hydrophilic Foam Dressing?

-The goals of donor site care are to promote rapid, moist wound healing, decrease pain at the site, and prevent infection. Choices of dressings vary among burn centers and include transparent dressings (e.g., Opsite), xenograft, silver sulfadiazine, silver-impregnated dressings, calcium alginate, and hydrophilic foam dressings. -Nursing care of the donor site is specific to the dressing selected. Several of the newer dressing materials offer decreased healing time, which facilitates earlier reharvesting of skin at the same site. The average healing time for a donor site is 10 to 14 days.

importance of layers of the skin?

-The skin is divided into three layers: the epidermis, dermis, and subcutaneous tissue (Figure 25-3). The epidermis, or nonvascular outer layer of the skin, is approximately as thick as a sheet of paper. It comprises many layers of nonliving epithelial cells that provide a protective barrier to the skin, hold in fluids and electrolytes, help to regulate body temperature, and keep harmful agents in the external environment from injuring or invading the body. -The dermis, which lies below the epidermis, is approximately 30 to 45 times thicker than the epidermis. The dermis contains connective tissues with blood vessels and highly specialized structures consisting of hair follicles, nerve endings, sweat glands, and sebaceous glands. Under the dermis lies the subcutaneous tissue, which contains major vascular networks, fat, nerves, and lymphatics. -The subcutaneous tissue acts as a heat insulator for underlying structures, which include the muscles, tendons, bones, and internal organs.

types of burn injury

-Thermal burns -Chemical burns -Smoke inhalation injury -Electrical burns

what happens toward the end of the emergent phase?

-Toward the end of the emergent phase, capillary membrane permeability is restored if fluid replacement is adequate. -Fluid loss and edema formation end. -Interstitial fluid gradually returns to the vascular space. -Diuresis occurs, and the urine has a low specific gravity.

Classification of Burn: Injury Extent of Burn

-Two commonly used guides for determining the total body surface area ---Lund-Browder chart --Considered more accurate --The Lund-Browder chart is considered more accurate because the patient's age, in proportion to relative body-area size, is taken into account (Figure 25-4 A). ---Rule of Nines --Used for initial assessment --The Rule of Nines, which is easy to remember, is considered adequate for initial assessment of an adult burn patient (Figure 25-4 B). --Sage Burn Diagram ( is a free Internet-based tool that is available for estimating TBSA burned) -The extent of a burn is often revised after edema has subsided and a demarcation of the zones of injury has occurred.

Emergent Phase: Nursing/Collaborative Management. Fluid theapy

-Two large-bore IV lines for >15% TBSA (For burns >30% TBSA, a central line for fluid and drug administration and blood sampling should be considered. An arterial line also should be considered if frequent ABGs or invasive BP monitoring is needed) -Type of fluid replacement based on size/depth of burn, age, and individual considerations (usually LR) -Parkland (Baxter) formula for fluid replacement (The Parkland (Baxter) formula for fluid replacement is the most common formula used, followed by the modified Brooke formula. It is important to remember that all formulas are estimates and must be titrated based on the patient's physiologic response. For example, patients with an electrical injury may have greater than normal fluid requirements) -Colloidal solutions (e.g., albumin) may be given. However, administration is recommended after the first 12 to 24 hours post burn, when capillary permeability returns to normal or near normal. After this time, the plasma remains in the vascular space and expands the circulating volume. The replacement volume is calculated based on the patient's body weight and TBSA burned.

what are some interventions for the emergent phase?

-fluid (for fluid shift) -oxygen -nutrition -something for pain (Morphine IV)

Acute Phase Complications: Endocrine

-↑ Blood glucose levels (Observe for transient increases in the patient's blood glucose levels as a result of stress-mediated cortisol and catecholamine release, resulting in increased mobilization of glycogen stores, gluconeogenesis, and subsequent production of glucose) -↑ Insulin production (An increase in insulin production and release is noted. However, the effectiveness of insulin is decreased because of relative insulin insensitivity, leading to an elevated blood glucose level) -Hyperglycemia (Hyperglycemia may also be caused by the increased caloric intake necessary to meet some patients' metabolic requirements. When this occurs, the treatment is supplemental IV insulin, not decreased feeding. Check blood glucose levels frequently, and give insulin as ordered)

Emergent Phase: Complications. Urinary?

-↓ Blood flow to kidneys causes renal ischemia -Acute tubular necrosis (ATN) -With full-thickness and major electrical burns, myoglobin (from muscle cell breakdown) and hemoglobin (from RBC breakdown) are released into the bloodstream and occlude renal tubules. -Adequate fluid replacement can counteract obstruction of the tubules.

what do we need instead of pulse ox?

ABG should be 80-100

what do all burn patients receive?

tetanus -Tetanus toxoid is given routinely to all burn patients because of the likelihood of anaerobic burn wound contamination. If the patient has not received an active immunization within 10 years before the burn injury, tetanus immune globulin should be considered

what areas are susceptible?

Areas that are most susceptible to contracture formation include the anterior and lateral neck areas, axillae, antecubital fossae, fingers, groin areas, popliteal fossae, knees, and ankles.

what is third spacing?

Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. (Examples of third spacing in burn injury are exudate and blister formation, as well as edema in non-burned areas)

CLINICAL MANI of upper and lower

upper: -blisters -edema -hoarseness -difficulty swallowing -copious secretions -stridor -substernal and intercostal retractions -total airway obstruction lower: -high degree suspicion if pt was trapped in a fire in an enclosed space -presense of facial burn or singed nasal hair -dyspnea -carbonaceous sputum -wheezing -hoarseness -altered mental status

explain the physiology map

after burn, this increases vascular permeability, which leads to edema and decreased intravascular volume, then increased hematocrit, increased viscosity, to increased peripheral resistance = burn shock

difference with electrical burns?

entrance (smaller) and exit