Chapter 51 continued
compliance with treatment and rehab regimen
Helps to prevent tightening of the skin and the development of contractures and scarring
traction
After the placement of the CEA, the patient is often placed in _________, which allows elevation of extremities and pressure relief.
unable to expand as the child grows
Contractures are especially devastating in the pediatric population because burned or grafted skin is?
prophylactic antibiotics
NOT recommended because of the potential of breeding antibiotic-resistant pathogens, and instead treatment is based on positive culture results.
post-traumatic stress disorder (PTSD), body image disorder, anxiety, and/or depression
psychosocial responses to rehabilitation phase of burn care
splinting
the most common method used to help prevent the formation of contractures
6.4 to 8.3; 3.5 to 5.0 fluid remaining in the intravascular space.
Assessment of nutritional status includes monitoring total protein and albumin levels. Normal serum total protein is _________ g/dL, and serum albumin is _______ g/dL. Adequate albumin also supports oncotic pressure that promotes ?
oral pain meds as soon as tolerated
IV narcotics are continued with pain management of burns while severe and unrelenting, however all efforts are made to transition to?
Stevens Johnson Syndrome and Toxic Epidermal Necrolysis
In both disorders, the epidermis separates from the dermal layer and sloughs
duodenal
In large burn injuries, longer nutritional support is required, and placement of a __________ feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures.
30%
Stevens-Johnson syndrome may involve less than ___% TBSA, whereas TEN may involve greater than ___% TBSA.
rehabilitative phase
This stage begins from the time the patient is admitted to the burn center and may last for several years, even extending well beyond discharge.
scheduled
with burns, pain medication is given on a _________ basis instead of on an as-needed (prn) basis, as this helps to better manage the pain over time and hopefully prevents it from becoming intolerable
Avoid pressure or disturbing it!
with grafts, avoid this!!
separates naturally; may take weeks/months (think of scabs)
with wound debridement, Natural devitalized tissue can ??? but may take ??
5-7 d post graft
when can the patient begin exercising the graft site post graft?
it is the growth of only thhe epidermal layer
why are CEAs so delicate ?
surgical wound debridement
performed as soon as possible after the burn; one of the most important factors in surviving a major burn
C. Location of the burn When using the urgent vs. non-urgent approach to client care, the nurse determines the priority is to assess the location of the burns that can lead to respiratory distress. (airway) _____________________ other answers and why they are wrong: Age of the client Answer Rationale: The client's age is important in the assessment of the client's burns, but is not the priority action by the nurse. Associated medical history Answer Rationale: The client's associated medical history is important in the assessment of the client's burns, but is not the priority action by the nurse. Cause of the burn Answer Rationale: The client's cause of the burns is important in the assessment of the client's burns, but is not the priority action by the nurse.
A nurse is assessing the depth and extent of injury on a client who has severe burns. Which of the following is the priority assessment? A. Age of the client B. associated medical history C. Location of the burn D. Cause of the burn
splinting and encouragement of rehabilitation exercises and ADLs
Essential to help prevent development of contractures and maintain joint function
371.4 mL/hr Correct Answer Rationale: The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL. STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 2,600 mL STEP 3: What is the total infusion time? 7 hr STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 2,600 mL/7 hr = X mL/hr X = 371.428571 STEP 6: Round if necessary. STEP 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 7 hr, it makes sense to administer 371.4 mL/hr.
IV LR for a burn client ordered: 5,200 mL in 1st 24 hr. He was burned 1hr ago. How many mL/hr should the nurse set the pump for the first hr?
pressure garments and specialty face masks
apply continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a year or more after injury in some patients.
oral mucosa, conjunctiva, vaginal canal, gastrointestinal tract, and urethral lining
areas which slough in SJS and TEN
procedural pain
associated with therapeutic activities such as wound care and physical therapy.
adverse medication reaction, viral infection, or reaction to the staphylococcal toxin.
cause of SJS and TEN
contractures
characterized as permanent tightening of the skin that may involve underlying muscles and tendons and result in limited mobility. The patient's personal motivation and compliance with therapy regimens play important roles
increased 2-3x
caloric needs for a burn patient can be increased as much as ?
allografts and xenografts
grafts that are intended to temporarily cover a wound
isolation guidelines some require contact precautions when entering all patient rooms
guidelines followed by most burn care centers to prevent cross contamination among burn patients
daily weight I&O calories counted
how to ensure that your patient is getting the right amount of calories with burn care
painful
if the donor site is partial thickness, it is typically very ?
PT and OT
important in the rehabilitation phase to begin working with the burn patient immediately, working on ROM, positioning, splinting, ambulation, and ADLs
enteral or PO nutrition; ileus and stress ulcers
in burn patients for nutrition, Early_________ is associated with a reduction in ___________ because it reduces the inflammatory mediators released by the body.
full thickness wound
includes both epidermis and dermis so donor site will not heal spontaneously
D. 54 percent Answer Rationale: Each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA _________________________ other answers and why they are wrong: 9 percent Answer Rationale: The rule of nines allows for an estimation of the extent of the body that has been burned by dividing anatomical regions into multiples of nines. Each arm represents 9% of the client's TBSA. 18 percent Answer Rationale: Each leg (anterior and posterior) represents 18% of the client's TBSA. 36 percent Answer Rationale: Both legs represent 36% of the client's TBSA.
A client has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which % of TBSA? A. 9 percent B. 18 percent C. 36 percent D. 54 percent
THE ANSWER IS : D, Administer IV fluids. Answer Rationale: Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids. other answers and why they are wrong: Clean and dress the wound. Answer Rationale: It is important for the nurse to clean and dress the wound in order to prevent the wound from becoming infected and to provide pain relief. However, there is another action that the nurse should take first. Administer pain medication. Answer Rationale: The client who has a burn injury can experience severe pain. It is important for the nurse to assess and treat the client's pain to provide comfort and make the cleansing and dressing of the wound more tolerable. However, there is another action that the nurse should take first. Administer a tetanus booster. Answer Rationale: The client who experiences a significant injury, such as a large burn, is at increased risk for developing an infection involving Clostridium tetani. While it is important to administer a tetanus booster to prevent infection, there is another action that the nurse should take first.
A client in the ED has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? A. Clean and dress the wound B. Administer pain meds C. administer a tetanus booster D. administer IV fluids
Erythema Answer Rationale: Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat. _______________ other answers and why they are wrong: Blistering Rationale: Blistering is an indication of a superficial partial thickness burn, involving injury to the upper third of the dermis. These injuries also are pink and moist, blanch to pressure and are very painful. Eschar Answer Rationale: Eschar is seen in clients who have a full thickness wound involving the epidermis and dermis. This is dead tissue that must be removed for healing to occur Absence of pain Answer Rationale: A thermal injury that is not painful can be classified as a deep full-thickness burn which extends into muscle, bone, or tendons.
A nurse is assessing a client using a heating pad. Which of the following is the first indication that the client is experiencing a superficial burn? A. blistering B. erythema C. Eschar D. Absence of pain
C. Talk with the client during wound care. Answer Rationale: Talking with the client while providing care assists in the development of the nurse-client relationship and demonstrates caring. ________________________ other answers and why they are wrong: Assign assistive personnel to keep his room neat and clean. Answer Rationale: This intervention is important for infection control but does not address the client's need for emotional support. Rotate nursing staff so he can have varied interactions. Answer Rationale: This intervention inhibits the development of a trusting, nurse-client relationship, which is an important component of providing emotional support. Keep family members aware of his condition. Answer Rationale: This intervention does not address the client's need for emotional support and may violate client confidentiality.
A nurse is developing a care plan for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include? A. Assign assistive personnel to keep his room neat and clean. B. Rotate nursing staff so he can have varied interactions. C. Talk with the client during wound care. D. Keep family members aware of his condition.
deep partial or full-thickness burns
what wounds is wound grafting used for ?
nutritional supplementation, often with placement of an NG tube along with supplemental vitamins and minerals
in patients with burns approx. 20% or greater, it is difficult to consume the amount of calories and protein needed for wound healing. So this is provided and often required
Monitor temperature (hyperthermia common for ~2 weeks)
in the acute / intermediate phase, you should monitor this for how long ?
• Wound color and consistency • Wound drainage • Eschar • Responses to therapeutic interventions • Graft sites • Pain • Weight • Serum total protein and albumin • Infection
in the intermediate phase the nurse observes for ?
ROM exercises
initiated on admission; may need to "hold" for new graft; collaborate with PT/OT
hyper metabolic and catabolic state
large burn injuries place the patient in this state
pain management meet caloric needs modulate hypermetabolism treat post burn pruritus DVT prevention (high risk) ROM exercises psychosocial support
main nursing actions in the acute and intermediate phase of burn care
decreases cosmetic result
meshed increases surface area but ?
infection from sepsis and multi organ failure
most common cause of death after the emergent phase of burn care
TPN
not often utilized among patients with burns because of its complication rates, including an increased risk for infection and hyperglycemia.
- Aerosolized heparin may be used - Balance between need for airway protection/support and risk of VAP(Ventilator Acquired Pneumonia) - Humidified oxygen (loosens secretions) - Turn, cough & deep breathe/incentive spirometer
nursing actions to promote respiratory status in the acute/intermediate phase of care for burns
psychological and rehabilitative support
of primary importance in the rehabilitation phase
procedural pain
often the most intense pain associated with a burn injury, and medication must be timed to allow for maximum absorption, as well as to time the most painful procedures during the peak effectiveness times of medications.
breakthrough pain
pain related to specific episodes associated with ADLs like walking
scarring to the face or hands
particularly traumatic to the patient and may result in appearance changes and disfigurement.
DVT
patient with burns in acute intermediate phase is at high risk for this, so practice prevention strategies
anxiolytics
patients are often given these during wound care procedures because they have a lot of fear regarding pain, appearance changes
morphine sulfate (morphine), fentanyl (Sublimaze), and/or hydromorphone (Dilaudid)
recommended IV narcotics especially used with dressing changes
- psychological considerations - improve body image and self concept - prevent and treat scars - promote activity tolerance
rehabilitation phase includes these nursing actions
- importance of applying pressure garments and or face masks - teach about burn prevention, sun protection and prevention of hyperthermia (lack of sweat glands)
teaching for patients with major burns in rehabilitation phase
background pain
the underlying pain from the primary injury that is continuous and ongoing
split thickness wound
these wounds can used sheetss or meshed grades
antimicrobial so still need antimicrobials
topical enzymatic agents are not ????—make sure they don't interfere with each other
oral antipruritic agents/gabapentin, environmental conditions, frequent lubrication of skin, diversional activities, educate: "pat don't scratch"
treatments for post burn pruritus
mechanical wound debridement
use of surgical tools, usually with daily dressing changes
chemical wound debridement
use of topical enzymatic agents
elevated HR (hypovolemia, pain, anxiety) elevated RR and BP (anxiety, pain) elevated temp (infection) low temp (hypothermia)
vital signs in the acute and intermediate phase burn care
• Pain/discomfort • Contractures • Scarring • Disfigurement • Limited mobility • Decreased mood • Flat affect • Fear • Anxiety
what does the nurse observe for in the rehabilitative phase ?
sunscreen, cover with clothes, avoid all irritating substances (perfumes in soaps, dyes in clothes, tight clothes), keep clean
what measures should the patient take to protect newly healed skin?