NUR 405 Exam 4

Nursing Diagnoses: Spinal Cord Injury

1. Impaired Gas Exchange 2. Impaired Physical Mobility 3. Ineffective Breathing Patterns 4. Altered Urinary and Bowel Elimination 5. Impaired Skin Integrity 6. Sexual Dysfunction 7. Self-Esteem Disturbance

Resuscitative Phase: Pathophysiology cont.

1. Inflammation and healing -Neutrophils and monocytes accumulate at the site of injury. -Fibroblasts and collagen fibrils begin wound repair within the first 6 to 12 hours after injury. 2. Immunologic changes -Burn injury causes widespread impairment of the immune system. -Skin barrier is destroyed. -Bone marrow is depressed. -Circulating levels of immune globulins are decreased. -WBCs develop defects. -high risk for infection

What is a Blood Transfusion?

1. Infusion of blood products for the purpose of restoring circulating fluid volume and increasing oxygen-carrying capacity 2. physician looks at potential risks and benefits 3. does pt really need the blood? 4. physician needs to review risks and benefits with pt and get a signed consent 5. Jehovah witnesses will probably refuse 6. look for pt more symptomatic, hemoglobin of 9 and below

Primary Injury

1. Initial disruption of spinal cord 2. Direct trauma to spinal cord d/t blunt or penetrating trauma 3. Compression by bone displacement, interruption of blood supply or distraction from pulling -spinal cord blood supply interrupted, could be breakage impacting spinal cord and compressing it 4. Penetrating trauma causes tearing and transection -transection: cut in it

Inhalation injury below the glottis (lower airway) (pg. 431)

1. Injury is related to the length of exposure to smoke or toxic fumes. 2. Pulmonary edema may not appear until 12 to 24 hours after the burn. -Manifests as acute respiratory distress syndrome

Fluid Therapy

1. Isotonic: 0.9% (NSS) 2. Hypertonic: 1.8%, 3%, 5% NaCL 3. PRBCs, FFP, Platelets 4. Albumin

*Parkland Formula*

1. *4 mL* Lactated Ringers per *Kg per % TBSA burn = Fluid Requirement* for First 24 hrs 2. Give ½ the first 8 hrs 3. Give ¼ the second 8 hrs 4. Give ¼ the third 8 hrs 5. 30% multiply by 30 not 0.3 6. 7,000 first 8 hours 7,000 divide by 8= 875/hr -next 16 hours get other half

3 stages of Shock

1. *Initial Stage*: cellular level, not noticed 2. *Compensatory Stage*: -Decreased CO -Hypotension -Cool, clammy -Blood flow to brain and heart maintained -low blood flow to kidneys, GI tract, lungs, and skin 3. *Progressive Stage*: -Compensatory Mechanisms fail, Interstitial fluid increases -Tachypnea, rales, hypotension, -Change in mental status, dysrhythmias, MI, oliguria, --ATN, acute renal failure, ulcers, GI bleed, liver failure, DIC 4. *Refractory Stage* -Decreased perfusion from vasoconstriction and decreased CO -Profound hypotension and hypoxia -Organ failure of liver, lungs, and kidneys -Recovery unlikely

Rehabilitation Phase -resuming functional role in society

1. *Rehabilitative Phase* begins on admission. -Focuses on correction of functional defect, prevention of scarring and contractures and psycho-social support for patient and family. 2. The rehabilitation phase can continue at a rehabilitative facility when the: -Burn wounds are healed -Patient is able to resume a level of self-care activity 3. This can occur as early as 2 weeks or as long as 7 to 8 months after the burn injury. 4. Goals for this period are to (1) assist the patient in resuming a functional role in society, and (2) rehabilitate from functional and cosmetic reconstructive surgery. Rehabilitation-focused activities that have been taking place during the earlier emergent and acute phases now begin in earnest once the patient's wounds have healed.

3 Burn Phases

1. *Resuscitative (Emergent) Phase* is the period of time required to resolve immediate problems resulting from the injury. Begins with the initial hemodynamic response to the injury and lasts until capillary integrity is restored -about 3 days, keep vital organs working, going through 2 huge fluid shifts -NPO until bowel sounds come back 2. *Acute Phase* begins when Pt is hemodynamically stable. -The major focus is wound healing and prevention of infection. -longest phase is acute: debriding, pain control, good nutrition (oral/NG) high protein to heal damaged tissue -goal is to get skin graft on and then send to rehab 3. *Rehabilitative Phase* begins on admission. -Focuses on correction of functional defect, prevention of scarring and contractures and psycho-social support for patient and family. -rehab maximizes what ability they have left, may get more surgeries for possible cosmetic reasons

Resuscitative Phase: Diuresis

1. *Transitioning to the Acute Phase* 2. Diuresis -*Interstitial to Plasma Fluid Shift* -*Nursing Care* -*VS=* start going up, holding bp med -*UO=* increasing (200/hr-> slow IVs), filling up foley bag -*BMP=* K dropping, may go a little low (was 7 before), swelling now coming down

Classification of Burn Injury: Depth of Burn

1. 1st Degree - *Superficial* -Involves the epidermis -epidermis 1-2 mm, skin still intact, no blister (sunburn) can be painful 2. 2nd Degree - *Superficial partial-thickness burn* -Involves the epidermis and some dermis 3. 2nd Degree - *Deep partial-thickness burn* -Involves the epidermis and deep dermis 4. 3rd Degree - *Full-thickness burn* -Involves fat, muscle, bone

platelets

1. 200-400ml 2. Pooled from multiple donors 3. Used for bleeding caused by thrombocytopenia

Types of Blood Products Packed Red Blood Cells (PRBCs) -most common

1. 250-350ml -need to look at volume on bag itself -set pump: 350 divided by how many hours to give over (usually 2-4) -each unit of blood increases hemoglobin by 1 point 2. Platelets and albumin removed 3. Severe anemia/replacement of acute blood loss of up to 500ml/unit

Albumin

1. 5% or 25% 2. Expands blood volume 3. Hypovolemic shock 4. stocked on floor, doesn't come from blood bank 5. trying to increase blood volume 6. in addition to normal saline 7. PRBCs and FFP both from blood bank, involve more checking due to incompatibility issues

Fluid Calculation Example

1. A 35 y.o. male was involved in a steam explosion at work. He was admitted directly to the burn unit. 2. Estimated BSA=50% Wt 70 Kg 3. 4mL X 70 Kg X 50%burn =_____in first 24 hrs 4. 4 x 70 x 50 = 14,000 mL

Emergency Department Care

1. ABC's 2. Identification of clinical insult/cause 3. Fluid resuscitation 4. Testing: EKG, CBC, complete metabolic panel, coags, liver function, lactic acid, type & screen, drug levels 5. Fluid resuscitation: Normal saline - most common. 2-3L initial then replacement to desired outcome. 6. Pharmacologic interventions: Antibiotics, vasopressors, Pain management

Pre-hospital Care

1. ABCDE -Maintain/establish airway -Assist with breathing if necessary -Support circulation/ CPR -Disability -Exposure

Emergency management

1. ABCs 2. Preventing extension of spinal cord injury w/ cervical collar and backboard -want to stabilize injury, dont want to get worse -log rolling -keep supine initially until know extent 3. Intubation? -intubate initially 4. Treat shock w/ IV fluids and vassopressors 5. Assess for other injuries 6. Control bleeding 7. CT scan -MRI sometimes used, but CT easier and quicker 8. History/Neuro assessment/ASIA tool -how did injury occur? 9. ABGs, lytes, glucose, Coags, hgb, hct

Transfusion Reactions

1. Acute hemolytic- ABO incompatibility **Life threatening Emergency** -Occur within the first 15 minutes, May be due to error in labeling of blood tubes, blood product etc., fever, back, abdominal chest or flank pain, tachypnea, SOB, tachycardia, hypotension, jaundice, bleeding, DIC, acute kidney injury, shock, death 3. Anaphylactic- Reaction to donor plasma proteins. ** can be life threatening if not recognized** -Anxiety, Abd pain, Urticaria (hives), wheezing, bronchospasm, hypotension, shock 4. Mild allergic reactions- sensitivity to foreign proteins. -Flushing, itching, urticaria, Common in patients with allergies. May need to pre-medicate with antihistamines and steroids -give antihistamine, Benadryl, steroids ahead of time if had this in past 5. Febrile Non-hemolytic- donor's WBC's or platelets react with the recipient's antibodies. -Sudden chills, rigors, and fever**Most common: 90% of reactions** Give acetaminophen -make sure to include temp -still stop

Spinal Cord Injury (SCI)

1. Damage to any part of the spinal cord causing a temporary or permanent loss of sensory, motor, or autonomic dysfunction below the level of injury 2. Causes: -MVA (38%) -Falls (30.5%) -Violence (13.5%) gun shot wounds, stabbing -Sport injuries (9%) diving, football -Degenerative older w osteoporosis -Cancer, hemorrhage 3. Permanent disability -don't know extent when first occurs -affects independence, economics -body image changes, possible wheelchair, bedridden -decrease in lifespan, higher mortality rate -affects all of the body systems 4. Psychosocial issues

Resuscitative Phase: Nursing and Collaborative Management cont

1. Airway management -Early endotracheal intubation --preferably orotracheal intubation. --Early intubation eliminates the necessity for emergency tracheostomy after respiratory problems have become apparent. In general, the patient with major injuries involving burns to the face and neck requires intubation within 1 to 2 hours after burn injury. --After intubation, the patient is placed on ventilatory assistance, and the delivered oxygen concentration is determined by assessing 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 may be needed to relieve respiratory distress secondary to circumferential, full-thickness burns of the neck and trunk. -Fiberoptic bronchoscopy --Humidified air and 100% oxygen --Within 6 to 12 hours after injury in which smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway. Significant findings include the appearance of carbonaceous material, mucosal edema, vesicles, erythema, hemorrhage, and ulceration. --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 necessary. If respiratory failure develops, intubation and mechanical ventilation are initiated. 2. Although burn management can be chronologically categorized as emergent, acute, and rehabilitative, the overall care requirements are not so easily classified. Depending upon the acuity of the patient, the duration of time spent in each phase varies greatly, and conditions improve and worsen unpredictably on an almost daily basis. Care changes accordingly. Although physiotherapy and occupational therapy are a focus of the acute and rehabilitative phases, proper positioning and splinting begin at the time of admission. 3. From the onset of the burn event until the patient is stabilized, nursing and collaborative management predominantly consists of airway management, fluid therapy, and wound care.

Anaphylactic Shock

1. An acute, life-threatening hypersensitivity (allergic reaction) 2. Antigen-antibody reaction from Food, insect bites, medications, latex, idiopathic reactions 3. Results in: -Massive vasodilation of blood vessels -pooling of blood in the periphery (decreased venous return) -poor/absent perfusion -body responds w/ vasoconstriction -respiratory distress or arrest

Neurogenic Shock

1. An imbalance between the sympathetic and parasympathetic stimulation of vascular smooth muscle which results in vasodilation 2. Causes -Spinal cord/medulla trauma, anesthetic agents, severe emotional stress, severe pain 3. Results in: -Poor perfusion, decreased cardiac output, impaired cellular metabolism

Watch for Transfusion Reaction

1. Anaphylactic, CP, SOB, fever, tachycardia, hypotension, back pain -don't tell pt what kind of reaction can occur -"if you feel different please tell me" -throat swelling, itching 2. Stop 3. Call MD and blood bank 4. Hang NSS -get normal saline and new fresh tubing 5. Vitals and UO -check urine output-> could have hemolytic reaction and get blood in urine 6. Save bag -blood bank will analyze why pt had reaction, save blood 7. Blood bank draws labs 8. Collect UA 9. Fill out paperwork 10. occasionally transfuse through blood warmer (ICU and hypothermic)

Incomplete Spinal Cord Injury

1. Anterior cord syndrome: direct injury to anterior spinal artery leads to compromised blood flow to anterior spinal cord, ~d/t acute compression, common w/flexion injury motor paralysis and loss of pain and temp sensation below level of injury, intact touch, position, vibration, and motion 2. Brown-Sequard Syndrome: damage to half of spinal cord ~d/t penetrating injury -opposite side of injury: loss of pain and temp below level of injury -Same side of injury: loss of motor function, light touch, pressure, position, and vibration

Nursing Management in Hemodynamic Monitoring

1. Assess your patient: baseline & as needed -General appearance, LOC, skin color/temperature, vital signs, respiratory status, peripheral circulation, urine output, changes in patient condition and/or numbers 2. Monitor and compare invasive measures with non-invasive 3. Monitor sites of invasive lines for: s/s infection, dressings/drainage, catheter placement, use of lines (measuring/capped/IVF), changes in readings

Treatment

1. Assessment: swan, aline or NBP (noninvasive bp), IV access, foley, watch MAP 2. Interventions -Oxygen therapy/vent -Nutrition: daily wts 3. Intra-aortic balloon pump (IABP) or VAD -increases coronary perfusion, decreases afterload, decreases cardiac workload 4. Antibiotics, blood glucose control (septic shock) 5. Benadryl and epinephrine (anaphylactic)

Types of Transfusions

1. Autologous donation / elective phlebotomy: -Patient donates their own blood prior to an operation, then it is available for them intra-op or post-operatively 2. Blood salvage: -collection and infusion of blood from an operative field or bleeding wound. Must be used within 12 hours, there is a loss of coagulation factors **Primarily used in cases of severe blood loss from trauma/surgery.*** 3. Therapeutic Apheresis -Donor's blood is collected, passed through an automated cell separator to remove specific components, then remaining components are returned to the patient. -Such as platelets & WBC's

Rehabilitation Phase:Nursing and Collaborative Management

1. Both patient and family actively learn how to care for healing wounds. -Because the patient may go home with small, unhealed wounds, education and "hands-on" instruction in dressing changes and wound care will be needed. -If needed, home care nursing services should be arranged to assist with care for the first few weeks post discharge. 2. An emollient water-based cream should be used. -(e.g., Vaseline Intensive Care Extra Strength) that penetrates into the dermis should be used routinely on healed areas to keep the skin supple and well moisturized, which will decrease itching and flaking. 3. Cosmetic surgery is often needed following major burns. -Postburn reconstructive surgery is frequently required following a major burn. It is important for the patient to understand the need for or possibility of further surgery before leaving the hospital. 4. Oral antihistamines may be used if itching persists. 5. no tight garments 6. Role of exercise cannot by overemphasized. 7. Constant encouragement and reassurance are necessary to maintain a patient's morale, particularly once the patient realizes that recovery can be slow and rehabilitation may need to be a primary focus for at least the next 6 to 12 months. -It is essential that patients be encouraged to discuss their fears regarding loss of their life as they once knew it, loss of function, temporary/permanent deformity and disfigurement, return to work and home life, and financial burdens resulting from a long and costly hospitalization and rehabilitation. 8. Address spiritual and cultural needs. -both these facets of a patient's life play a role in recovery. Pastoral care and cultural groups may be helpful resources to the patient, caregiver, and health care team. Patients can be assisted toward a realistic and positive appraisal of their particular situation, emphasizing what they can do instead of what they cannot do. 9. In a society that values physical beauty, alterations in body image can result in psychologic distress. Encouraging appropriate independence, an eventual return to preburn activities, and interactions with other burn survivors will involve the patient in familiar activities that may bring comfort and help to restore self-esteem. Counseling, which may have started in the acute phase of care, can be offered after discharge. Patients appreciate reassurance that their feelings during this period of adjustment are normal, and that their frustration is to be expected as they attempt to resume a normal lifestyle.

Rehabilitation Phase:Pathophysiologic Changes

1. Burn wound heals either by *primary intention or by grafting.* 2. Layers of epithelialization begin to rebuild the tissue structure. 3. Collagen fibers add strength to weakened areas. 4. The new skin appears flat and pink. 5. even darker complected pt needs to keep out of sun, new baby skin 6. In approximately 4 to 6 weeks, the area becomes raised and hyperemic. -If adequate ROM is not instituted, the new tissue will shorten, causing a contracture. 7. Mature healing is reached in 6 months to 2 years. -Mature healing is reached in about 12 months, when suppleness has returned and the pink or red color has faded to a slightly lighter hue than the surrounding unburned tissue. It takes longer for more heavily pigmented skin to regain its dark color because many of the melanocytes have been destroyed. 8. Skin never completely regains its original color. -Frequently, the skin does not regain its original color. Paramedical cosmetic camouflage, the implantation of pigment within the skin, can help even out unequal skin tones and improve the patient's overall appearance and self-image. 9. 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. 10. *Pressure can help keep scar flat.* -It is believed that pressure can help keep a scar flat. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments (e.g., Jobst garments). They should never be worn over unhealed wounds and are removed only for short periods while bathing. -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., diphenhydramine [Benadryl]) help reduce the itching. Massage oil, silicone gel sheeting (e.g., Biodermis), gabapentin (Neurontin), and injectable steroids also may be helpful. 11. Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch. -As "old" epithelium is replaced by new cells, flaking will occur. The newly formed skin is extremely sensitive to trauma. Blisters and skin tears are likely to develop from slight pressure or friction. -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.

Carbon monoxide (CO) poisoning

1. CO is produced by the incomplete combustion of burning materials. 2. Inhaled CO displaces oxygen. -Hypoxia -Carboxyhemoglobinemia (hemoglobin combined w CO) -Death when carboxyhemoglobinemia blood levels greater than 20% 2. Symptoms: H/A, weakness, NV, confusion, dizziness, SOB -Treat with 100% humidified oxygen. -CO poisoning may occur in the absence of burn injury to the skin. 3. The majority of deaths at a fire scene are the result of inhaling certain smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide. 4. grill outside of house-> don't breathe in CO 5. hemoglobin will grab onto CO instead of O2 and not get rid of it 6. confusion d/t brain not getting enough O2 7. smoke detectors and CO detectors -can get combined 8. can get carbon monoxide burn with flame in enclosed space

Resuscitative Phase: Complications

1. Cardiovascular system -Dysrhythmias and hypovolemic (burn) shock -Impaired circulation to extremities -Tissue ischemia -Necrosis -Impaired microcirculation and ↑ viscosity → sludging --Initially, blood viscosity is increased because of the fluid loss that occurs in the emergent period. Microcirculation is impaired by damage to skin structures that contain small capillary systems. These two events result in a phenomenon termed sludging. Sludging is corrected by adequate fluid replacement. -Burn patients are at an increased risk for venous thromboembolism (VTE) if one or more of the following conditions are present: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lower-extremity trauma, and prolonged immobility. VTE prophylaxis with anticoagulant drugs should be started, unless contraindicated. 2. Respiratory system -Upper respiratory tract injury --Edema formation can be massive and the onset insidious. --Mechanical airway obstruction and asphyxia --results from direct heat injury or edema formation. --Upper airway distress may occur with or without smoke inhalation. --Mechanical obstruction of the airway is not limited to the patient with flame burns to the upper airway. Swelling that accompanies scald burns to the face and neck can be lethal, as can pressure from accumulated edema compressing the airway externally. --Flame burns to the neck and chest may contribute to respiratory difficulty because the inelastic eschar becomes tight and constricted as a result of the underlying edema. -Lower airway (inhalation) injury --Direct insult at the alveolar level secondary to the inhalation of toxic fumes or smoke. --Interstitial edema that prevents diffusion of oxygen from the alveoli into the circulatory system. --Patient may not exhibit signs during first 24 hours -Pneumonia -Pulmonary edema -Fiberoptic bronchoscopy and carboxyhemoglobin blood levels can be used to confirm a suspected inhalation injury. -Another diagnostic indicator may be a history of prolonged exposure to smoke or fumes. -Sputum that contains carbon may be present. -You must be especially sensitive to signs of impending respiratory distress such as increased agitation, restlessness, or change in the rate or character of respirations, as the symptoms may not be present immediately. -Generally, no correlation exists between the extent of TBSA burn and the severity of inhalation injury because inhalation injury is a factor of time exposure plus the type and density of the material inhaled. -The initial chest x-ray may appear normal on admission, with changes noted over the next 24 to 48 hours. -Arterial blood gas (ABG) values may be within the normal range on admission and then may change during hospitalization. 3. Urinary system -↓ Blood flow to kidneys causes renal ischemia. -Acute tubular necrosis (ATN) --With full-thickness and 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 myoglobin and hemoglobin obstruction of the tubules. -keep urine output above 30 to avoid/minimize AKI

Acute Care Period: Critical Care Unit

1. Cardiovascular, respiratory support 2. Hemodynamic monitoring 3. Nutritional support 4. Monitor for skin breakdown 5. Prevention of reversible consequences of shock 6. Monitor for worsening of condition 7. Emotional/end of life support

Incomplete

1. Cauda Equina Syndrome: damage to lumber and sacral nerve roots, asymmetrical distal weakness and patchy sensation to lower extremities, may have flaccid paralysis of lower extremities, loss of sensation over saddle area (perineal area—> loss of bladder control), areflexic bowel and bladder, pain 2. Central cord Syndrome: damage to central spinal cord, most often in cervical region, seen with older people ~d/t hyperextension in people with DJD (degenerative joint disease) motor weakness, altered sensation, and burning pain in upper extremities, lower not affected 3. Conus Medullaris Syndrome: damage to lowest part of spinal cord, leg motor function preserved, weak, or flaccid, loss of sensation to perianal area, areflexic bowel and bladder, impotence 4. older people: already have degenerative disease and then fall forward

Types of Burn Injury: Thermal Burns

1. Caused by flame, flash, scald, or contact with hot objects -Scald injuries can occur in the bathroom or while cooking (steam from hot water) -Flash, flame, or contact burns can occur while cooking, smoking, burning leaves in the backyard, or through misuse of gasoline or hot oil. 2. Most common type of burn 3. Severity of injury depends on -Temperature of burning agent -Duration of contact time

Central Venous Pressure (CVP)

1. Central line catheter 2. Measure central venous pressure (CVP) / right atrium pressure 3. Normal 2-6 mmHg -Low readings indicate hypovolemia. -High readings indicate fluid overload. 4. Possible complications: infection (central line-associated blood stream infection- CLABSI), pneumothorax, air emboli, bleeding

Classifications of shock (pg. 1588)

1. Classified based on the cause -Anaphylactic -Cardiogenic -Hypovolemic -Neurogenic -Septic

Degree of injury (pg. 1422)

1. Complete: Loss of sensory and motor function below level of injury 2. Incomplete: mixed loss of voluntary motor activity and sensation 3. 5 major syndromes -Anterior cord Syndrome -Brown-Sequard Syndrome -Cauda Equina Syndrome -Central Cord Syndrome -Conus Medullaris Syndrome

Non-invasive Monitoring

1. Continuous blood pressure (dynamap) 2. Capillary refill 3. Pulses- arterial and peripheral 4. Pulse Ox (continuous SpO2/ noninvasive arterial oxygen monitoring) 5. Transesophageal ultrasound (TEE)

Invasive: Arterial Lines

1. Continuous blood pressure monitoring 2. Via artery: usually radial 3. Allen's test 4. Blood access: labs and ABGs 5. Indications: Hypotension, hypertension, resp failure, shock, during surgery, admin of vasoactive drugs 6. Risks: Hemorrhage, infection, thrombus, NV impairment 7. nursing management -flush system every 1-4 hrs to determine that the pressure bag is inflated to 300 mm Hg, flush bag contains fluids, system is delivering a continuous slow (approximately 3 mL/hr) flush -evaluate neurovascular status distal to the arterial insertion site hourly

Blood Transfusion Risks (pg. 650)

1. Disease transmission 2. Transfusion related graft vs. host disease (GVHD) 3. Bacterial contamination- proper storage and administration within temperature and time restrictions 4. Transfusion-related Acute Lung Injury (TRALI) 5. Transfusion reactions ** 6. Iron Overload 7. Circulatory Overload -fluid administered faster than circulation can accommodate -people with cardiac/renal disease at risk 8. Multiple/Massive transfusion

Blood Donation

1. Donor blood 2. Collected during blood drives and at blood banks 3. Qualifications -certain meds may exclude you from giving blood (blood thinners) -cannot if pregnant, STD, cold, hx of drug abuse, sickle cell disease, tattoo in last year 4. Only 3% of age-eligible people donate blood yearly

Pre-hospital Care

1. Electrical injuries -Remove patient from contact with source. 2. Chemical injuries -Brush solid particles off the skin. -Use water lavage. -Any clothing containing the chemical must also be removed as the burning process continues while the chemical is in contact with the skin. -The affected area should be flushed with copious amounts of water to irrigate the skin anywhere from 20 minutes to 2 hours post exposure. Tap water is acceptable for flushing eyes exposed to chemicals. -Tissue destruction may continue for up to 72 hours after a chemical burn. -Cooling of the injured area (if small) within 1 minute helps minimize the depth of the injury. 3. Small thermal burns -Cover with clean, cool, tap water- dampened towel. 4. Large thermal burns -Airway --Check for patency, soot around nares/on the tongue, singed nasal hair, darkened oral or nasal membranes. -breathing --Check for adequacy of ventilation. -circulation --Check for presence and regularity of pulses, and elevate the burned limb(s) above the heart to decrease pain and swelling. -To prevent hypothermia, large burns should be cooled for no longer than 10 minutes. 5. do not remove limb that was electrically burned, throw something onto limb to break contact and then start assessment 6. thermal: keep pt warm, moisten w warm water, no ice, good patient is screaming-> breathing, get worried when sleeping, wake up to ensure pt is breathing 7. Large thermal burns -Do not immerse in cool water or pack with ice because doing so might lead to extensive heat loss. Never cover a burn with ice, as this can cause hypothermia and vasoconstriction of blood vessels, further reducing blood flow to the injury. -Remove burned clothing to prevent further tissue damage. Adherent clothing should be left in place until the patient is transferred to a hospital. -Wrap in clean, dry sheet or blanket to prevent further contamination of the wound and to provide warmth. 8. Inhalation injury -Observe for signs of respiratory distress or compromise. -Treat quickly at the scene if they are to survive. If CO intoxication is suspected, the patient should be treated with 100% humidified O2. Patients with both body burns and inhalation injury must be transferred to the nearest burn center.

Acute Phase - Nursing and Collaborative Management other care measures

1. Facial care -Performed by the open method -The face is highly vascular and is subject to a great amount of edema. It often is covered with ointments and gauze but is not wrapped, to limit pressure on delicate facial structures. 2. Eye care for corneal burns -Antibiotic ointment is used. -Periorbital edema may frighten patient --You must provide assurance that the swelling is not permanent. -An ophthalmology examination should occur soon after admission for all patients with facial burns. -Instillation of methylcellulose drops or artificial tears into the eyes for moisture provides additional comfort. 3. Hands and arms should be extended and elevated on pillows or slings. 4. Ears should be kept free of pressure. -No use of pillows 5. Perineum must be kept as clean and dry as possible. -In addition to providing hourly urine outputs, an indwelling catheter prevents urine contamination of the perineal area. Regular, once- to twice-daily perineal and catheter care in the presence or absence of a perineal burn wound is essential. 6. Routine laboratory tests -to monitor fluid and electrolyte balance. ABGs are drawn to determine adequacy of ventilation and perfusion in all patients with suspected or confirmed inhalation or electrical injury. 7. 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 extravasated fluid back into the vascular bed. Exercise of body parts also maintains function, prevents contractures, and reassures the patient that movement is still possible. 8. Drug therapy -Analgesics and sedatives ordered to promote patient comfort. Morphine Hydromorphone (Dilaudid) Haloperidol (Haldol) Lorazepam (Ativan) Midazolam (Versed) -Early in the postburn period, IV pain medications should be given because (1) onset of action is fastest with this route, (2) GI function is slowed or impaired as the result of shock or paralytic ileus, and (3) 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. -The need for analgesia must be reevaluated frequently 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. -Tetanus immunization --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. -Antimicrobial agents --Topical agents After the wound has been cleansed, topical antimicrobial agents are applied and covered with a light dressing Some topical burn agents penetrate the eschar, thereby inhibiting bacterial invasion of the wound dressing. *Silver sulfadiazine (Silvadene)* -(Flamazine) *Mafenide acetate* (Sulfamylon) *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. *Others* --Systemic agents are not usually used in controlling burn flora because little or no blood supply to the burn eschar is available, and consequently, delivery of the antibiotic to the wound is limited. --Initiated for invasive burn wound sepsis, pneumonia etc --In addition, the routine use of systemic antibiotics increases the chance of development of multiresistant organisms. --Sepsis remains a leading cause of death in the patient with major burns, which may lead to multiple organ dysfunction syndrome. -VTE (venous thrombo-embolism) prophylaxis --Low-molecular-weight heparin (enoxaparin [Lovenox]) or low-dose unfractionated heparin (heparin [Hep-Lock]) is started. --Those at high bleeding risk- sequential compression devices and/or graduated compression stockings be used until the bleeding risk is decreased and heparin can be started. --lower extremity burns, obesity 9. Nutritional therapy -Early and aggressive nutritional support within hours of burn injury --Decreases mortality and complications --Optimizes wound healing --Minimizes negative effects -Hypermetabolic state --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. --Caloric needs are about 5000 kcal/day. 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. --Early, continuous enteral feeding promotes optimal conditions for wound healing. --Supplemental vitamins (as early as the emergent phase) and iron may be given (often started in the acute phase.) --proportional to the size of the wound occurs after a major burn injury.

Resuscitative Phase: Nursing and Collaborative Management

1. Fluid therapy -Two large-bore IV lines for >15% TBSA --It is critical to establish IV access that can accommodate large volumes of fluid. 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 -*Parkland (Baxter) formula* for fluid replacement --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. -*Crystalloids* such as lactated Ringer's solution. --have electrolytes -*Colloidal solutions* -such as albumin -usually after 12 to 24 hrs post burn or a combination of the 2 --protein, holds fluids keeping bp up --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. -Paramedics generally give IV saline until the patient's arrival at the hospital. 2. Assessment of the adequacy of fluid resuscitation is best made using clinical parameters. Urine output is the most commonly used parameter.

Pulmonary Artery Catheter/Swan Ganz

1. For complicated cardiac, pulmonary, intravascular volume problems 2. Ports for fluids, withdrawal of blood for labs, to measure heart pressures and cardiac output, and monitor core temp 3. Pulmonary capillary wedge pressure (PCWP or wedge) normal 4-12 mmHg 4. PCWP Increased with fluid overload and heart failure 5. nursing management -chest xray must confirm the catheter's position -secure it at the point of entry into the skin -note and record the measurement of the exit point -apply an occlusive dressing and change it according to policy 6. complications -infection, dysrhythmias

Complications -general complications of any spinal cord injury

1. GI: -Gastric distension -Paralytic ileus -Stress ulcers -Dysphagia -decreased GI motor activity, emptying -produce more hydrochloric acid-> stress ulcers-> PPIs, histamine blockers 2. Bowel: -Neurogenic bowel -Stool retention and constipation -Impaired peristalsis -Incontinence -Impaction 3. Integumentary: Pressure injuries leading to infection and sepsis -not getting out of bed, sitting for long periods of time -sitting in incontinence 4. Thermoregulation: poikilothermia -takes on ambient temp of room -cannot sweat or shiver to reg body temp esp higher cervical injuries 5. Metabolic needs: increased nutritional needs -try to start TPN/tube feedings within 72 hrs of injury -need protein to heal, muscles are atrophying and losing weight 6. Lean body mass decreases, muscles atrophy 7. PV problems: VTE -peripheral vascular problems due to immobility and blood statuses 8. Pain: nociceptive and neuropathic -neuropathic: nerve pain r/t injury itself, pins and needles when hitting elbow -can be sensitive to someone touching them -nociceptive: chronic aching tissue pain due to injury -can have combination of both types of pain

Treatment for shock

1. Goal: Identify and treat the cause !!! 2. Maintain oxygen perfusion, control bleeding, support circulatory status, maintain body temperature, manage pain (if VS allow), provide emotion support to patient and family

Nursing Interventions: Long-term

1. Hyperactive reflexes: control with antispasmodics Baclofen (Lioresol), dantrolen (Dantrium), tizanidine (Zanaflex) 2. Rehabilitation and home care 3. Neurogenic bladder and bowel -antispasmodics to help control bladder/bowel 4. Skin -reposition at least every 2 hours while in bed and every 15-20 mins when in a chair or wheelchair 5. Sexuality 6. Grief and depression

Classification of Burn Injury: Location of Burn

1. Location of the burn is related to the severity of the injury -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 tissue formation (eschar). These injuries may also signal the possibility of inhalation injury and respiratory mucosal damage. -Hands, feet, joints, eyes → self-care -- make self-care very difficult and may jeopardize future function. Burns of the hands and feet are challenging to manage because of superficial vascular and nerve supply systems and the need to maintain their function during healing. -Ears, nose, buttocks, perineum → infection --susceptible to infection because of poor blood supply to the cartilage. --Burns to the buttocks or perineum are highly susceptible to infection. --areas that harbor lot of bacteria: supra pubic catheter, temp colostomy 2. Circumferential burns of the extremities can cause circulatory compromise and patients may also develop *compartment syndrome*. -Patients may also develop compartment syndrome from direct heat damage to the muscles and subsequent edema and/or preburn vascular problems -compartment syndrome w circumferential burn--> if tissue cannot swell, squeezes on arteries losing pulse 3. *Older adults heal more slowly* than younger adults. 4. Preexisting cardiovascular, respiratory, and renal diseases contribute to poorer prognosis. -Any patient with preexisting heart, lung, or kidney disease has a poorer prognosis for recovery because of the increased demands placed on the body by a burn injury. 5. Diabetes mellitus contributes to poor healing and gangrene. -The patient with diabetes mellitus or peripheral vascular disease is at high risk for poor healing and gangrene, especially with foot and leg burns. 6. Concurrent fractures, head injuries, or other trauma also lead to poor prognosis.

Autonomic Dysreflexia

1. Massive, uncompensated cardiovascular reaction -after spinal shock concludes 2. Result of noxious stimuli: distended bowel or bladder, pressure ulcer 3. Vasoconstriction below level of injury 4. HTN, bradycardia, dysrhythmias, pounding H/A, diaphoresis, flushing, piloerection (goose bumps), nasal congestion, blurred vision, anxiety, nausea 5. Elevate HOB 45 degrees 6. Remove stimuli -constrictive clothing -get rid of stimuli—> bladder scan, last BM? -if let go could have seizures, stroke, MI, death

Classification of Spinal Cord Injury

1. Mechanism of injury 2. Level of injury 3. Degree of injury

Hemodynamic Monitoring

1. Monitoring of blood flow and pressures within the body 2. Balance between blood flow, resistance and pressures within the body 3. Focuses on circulation, perfusion, and tissue oxygenation 4. devices must be discontinued before going to med surge unit 5. Aids in diagnosis 6. Assist in guiding therapies and treatments 7. Evaluate patient's response to current therapies and treatments 8. Indications: -Assess heart function, fluid balance, effects of drugs that affect cardiac output -Monitoring perfusion, especially in situations with unstable BP

Types of Hemodynamic Monitoring

1. Non-Invasive 2. Invasive

Gerontologic Considerations

1. Normal aging puts the patient at risk for injury because of: -Unsteady gait -Failing eyesight -Diminished hearing -The fact that wounds take longer to heal 2. As people age, skin becomes more dry, wrinkled, and loose. The dermal layer thins, and loss of elastic fibers, a reduction in subcutaneous adipose tissue, and a decrease in vascularity occur. As a result, the thinner dermis, with reduced blood flow, sustains deeper burns with poorer rates of healing. 3. Once injured, the older adult has more complications in the emergent and acute phases of burn resuscitation because of preexisting medical conditions. For example, older patients with diabetes, heart failure, or chronic obstructive pulmonary disease will have morbidity and mortality rates exceeding those of healthy, younger patients. In older patients, pneumonia is a frequent complication, burn wounds and donor sites take longer to heal, and surgical procedures are less well tolerated. Weaning from a ventilator can be a challenge, and delirium from medication/anesthesia may be a distressing, although usually self-limiting, outcome. It usually takes longer for these patients to rehabilitate to the point where they can safely return home. For some, a return home to independent living may not be possible. As the population ages, development of strategies to prevent burn injuries in this population is a priority.

Burns

1. Occur when injury to the tissues of the body is caused by heat, chemicals, electrical current, or radiation 2. Should be *viewed as preventable* 3. LEARN NOT TO BURN 4. Types of Burn Injury -Thermal burns -Chemical burns -Smoke inhalation injury -Electrical burns -Cold thermal injury (skip) 5. The resulting effects are influenced by temperature of the burning agent, duration of contact time, and type of tissue that is injured. 6. An estimated 500,000 Americans seek medical care each year for burns. 7. Approximately 40,000 people are hospitalized, one half of whom require care in specialized burn centers. 8. About 4,000 Americans die annually as a direct result of their burns. 9. The highest fatality rates occur in children 4 years of age and younger, and in adults over the age of 65. 10. Although burn incidence has decreased over the past few years, burn injuries still occur too frequently, and most should be viewed as preventable. The focus of burn prevention programs has shifted from concentrating on individual blame and changing individual behaviors to include more legislative changes. 11. The aim of these changes is to make improvements in the environment. Coordinated national programs include child-resistant lighters, nonflammable children's clothing, tap water anti-scald devices, fire-safe cigarettes, stricter building codes, hard-wired smoke detectors/alarms, and fire sprinklers. 12. You can advocate for burn risk reduction strategies in the home. You also can educate workers to reduce burn injuries in the work setting. 13. our job as nurses to teach patients and families to avoid obstacles and assess home to avoid risk of burn

Spinal Shock

1. Occurs shortly after injury 2. Loss of deep tendon and sphincter reflexes, loss of sensation and flaccid paralysis below level of injury 3. Lasts days to weeks -can have improvement after 4. Hard to determine extent of injury -cannot give prognosis

Neurogenic Shock

1. Occurs with injuries T6 and above -T6: thoracic (T10 hip level) -cervical, thoracic, lumbar -dermatomes in book different colors of where sensation occurs 2. Causes peripheral vasodilation, venous pooling, decreased cardiac output 3. S & S - hypotension, bradycardia, temperature deregulation -temp deregulation: body not regulating own temp, takes on temp of atmosphere -want BP over 90 systolic -also look at MAP -don't want hypotension so bad that it lessens blood flow to spinal cord 4. Can continue for 1-3 weeks

Secondary Injury

1. Ongoing progressive damage 2. Causes further permanent damage 3. Results in edema, ischemia and inflammation 4. Blood brain barrier disruption, neuron destruction 5. Spinal cord compression 6. Apoptosis for weeks -cell death: apoptosis 7. Irreversible nerve damage and permanent neurological deficit

Procedure

1. Order to transfuse, rate -order: "transfuse so many units over so many hours" 2. Given over 2-4 hours -platelets and albumin and FFP only infuse over 15-20 mins, no pump only roller clamp, smaller volume 3. Check IV site and gauge (need #22 at least) -PICC, central line #1 not likely to infiltrate -but can give peripheral -flush IV first to ensure its patent -must hang 20-30 mins after receiving -look for placement too, antecubital not ideal 4. Premeds? -usually Tylenol/Benadryl ordered ahead of time to prevent transfusion reaction (1 hr prior) only if someone has potential for reaction 5. Pump only, NSS only with blood "Y" tubing -"Y" tubing: 2 things go in 1: blood and NSS 0.9%, only fluid that can be hung with blood 6. Hold other IV fluids/TPN? -need order 7. Slip to blood bank -blood cannot be sent through tube system, need to take slip and compare paper work at blood bank, must hand it to someone cannot set down 8. First set of vitals -prime with saline and take vitals before getting blood

Nurses' Role in the Care of Patients in Shock

1. Prevention, identification of high risk patients 2. Early recognition of signs and symptoms 3. Strict and often assessment and monitoring of hemodynamics, labs, physical assessment. 4. Monitoring of interventions for efficacy 5. Prevention and early treatment of preventable complications 6. Assessment, assessment, assessment !! 7. When in doubt, ask......

Homologous- transfusion from a donor

1. Random donor: from anyone (blood drive) 2. Directed/Designated donor: chosen donor -could give at a donation center and designate to you specifically 3. Type and crossmatch testing and screening for 9 diseases 4. Matched to recipient before transfusion 5. processed through blood bank and given to hospitals -hospitals order certain number of units of types needed

Complications

1. Respiratory -Above C3- total loss of resp muscles -above C5 intubate stat -Aspiration, atelectasis, pneumonia -cannot take deep breaths, no chest expansion, sats dropping rapidly, cannot cough/move secretions -can go into pulmonary edema d/t fluid overload issues -want O2 over 92% -if high up may need initial intubation 2. Cardiovascular: T6 or above -bradycardia, hypotension (neurogenic shock) 3. Urinary: neurogenic bladder -Overdistension, incontinence, reflux of urine into kidneys -check amt of volume w bladder scanner and then straight cath -one of the reasons of renal failure—>kidney stones, pyelonephritis -bladder can happen at any level

Types of Burn Injury: Electrical Burns

1. Result from coagulation necrosis caused by intense heat generated from an electric current 2. May result from direct damage to nerves and vessels, causing tissue anoxia and death 3. entrance and exit wounds 4. Severity of injury depends on -Amount of voltage -Tissue resistance --Tissue densities offer various amounts of resistance to electric current. For example, fat and bone offer the most resistance, whereas nerves and blood vessels offer the least resistance. -Current pathways -Surface area -Duration of the flow 5. Current that passes through vital organs will produce more life-threatening sequelae than current that passes through other tissue. 6. Electrical sparks may ignite the patient's clothing, causing a combination of thermal and electrical injury. 7. Severity of injury can be difficult to assess, as most damage occurs beneath the skin. -*Iceberg effect*: The severity of an electrical injury can be difficult to determine as most of the damage occurs below the skin 8. Patients are at risk for *dysrhythmias*, severe *metabolic acidosis*, and *myoglobinuria= ATN (acute tubular necrosis=acute kidney injury)* -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. 9. As with inhalation injury, a rapid assessment of the patient with electrical injury must be performed. Transfer to a burn center is indicated. 10. Electrical current may cause muscle spasm strong enough to fx bones -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. -muscle cells damaged and break open 11. 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. 12. don't always look seriously ill

Types of Burn Injury: Smoke Inhalation Injuries

1. Result from inhalation of hot air or chemicals 2. Cause damage to respiratory tract 3. Major predictor of mortality in burn victims -rapid assessment is critical 4. Need to be treated quickly 5. Three types -Carbon monoxide poisoning (not the sooty type) -Inhalation injury above the glottis -Inhalation injury below the glottis (alveoli now damaged-> ARDS, pneumonia) 6. Fortunately, gases are cooled to body temperature before they reach the lung tissue. 7. Although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis close as a protective mechanism. Redness and airway swelling (edema) may result when damage occurs. 8. singed nasal hair, no eyebrows 9. put ET down right away before obstructs from swelling

Types of Burn Injury: Chemical Burns

1. Result from tissue injury and destruction from acids, alkalis, and organic compounds -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. 2. Alkali burns are hard to manage because they cause protein hydrolysis and liquefaction -Damage continues after alkali is neutralized -Alkali burns can be more difficult to manage than acid burns because alkaline substances are not neutralized by tissue fluids as readily as acid substances. Alkalis adhere to tissue, causing protein hydrolysis and liquefaction. Alkalis are found in oven and drain cleaners, fertilizers, and heavy industrial cleansers. 3. Results in injuries to -Skin -Eyes (splashed w a chemical) -Respiratory system -Liver and kidney 4. Acids are found in many household cleaners and include hydrochloric, oxalic, and hydrofluoric acid. 5. people who work in industries/farms handle lot of chemicals 6. chemical burns tend to keep burning, need to flush for long periods of time 7. Chemical should be quickly removed from the skin. 8. Clothing containing the chemical should be removed. 9. Tissue destruction may continue up to 72 hours after a chemical injury.

Septic Shock

1. Severe sepsis with hypotension that does NOT respond to usual medical management or hypotension that does NOT respond to fluid resuscitation, causing an alteration in organ perfusion. 2. Causes: Infection 3. Severity and outcome can be affected by: -Age of patient, health of patient, bacterial vs. viral, available medical technology, antibiotic misuse

Hypovolemic Shock

1. The result of significant fluid loss, that alters the amount of circulating body fluid. 2. Causes -Blood loss from surgery, traumatic injuries (GSW, stab), ruptured aneurysms, hemorrhagic pancreatitis, GI bleeding, long-bone fractures. -Non-hemorrhagic losses such as vomiting and diarrhea, thermal (burns) injuries, "third spacing" , cirrhosis, diabetic ketoacidosis 3. Results in: -Insufficient volume for heart to pump -decreased preload -decreased CO -decreased perfusion......

Classification of Burn Injury

1. Severity of injury is determined by -Depth of burn -Extent of burn in percent of TBSA -Location of burn -Patient risk factors 2. Burns have been defined by degrees (1st, 2nd, 3rd, and 4th). 3. ABA advocates categorizing the burn according to depth of skin destruction. -*Partial-thickness burn* -*Full-thickness burn* 4. The American Burn Association (ABA) uses referral criteria to determine which *major burn injuries* should be treated in burn centers with specialized facilities. 5. The majority of patients with *minor burn injuries* can be managed in community hospitals.

Resuscitative Phase: Clinical Manifestations

1. Shock from pain and hypovolemia -Frequently, areas of full-thickness and deep partial-thickness burns are initially anesthetic because the nerve endings are destroyed. -Superficial to moderate partial-thickness burns are painful. 2. Blisters -filled with fluid and protein may form in partial-thickness burns. Fluid is not actually lost from the body as much as it is sequestered in the interstitial spaces and third spaces. 3. Paralytic ileus -The patient with a larger burn may have signs of an adynamic ileus, such as absent or decreased bowel sounds, as a result of the body's response to massive trauma and potassium shifts. 4. Shivering -may occur as a result of chilling that is caused by heat loss, anxiety, or pain. 5. Altered mental status -Most burn patients are quite alert and can provide answers to questions shortly after the injury, or until they are intubated. They often are frightened and benefit from calm reassurances and simple explanations by all health care providers. -Unconsciousness or altered mental status in a burn patient is usually not a result of the burn. The most common reason for unconsciousness or altered mental status is hypoxia associated with smoke inhalation. -d/t pain, electrolyte imbalances 6. Ongoing nursing assessment of the ABCs, vital signs, cardiac rhythm, oxygenation, and level of consciousness are priorities in the emergent phase of burn care. 7. Other possibilities include head trauma, history of substance abuse, or excessive amounts of sedation or pain medication.

Rehabilitation Phase: Complications

1. Skin and joint contractures -Most common complications during rehab phase -Positioning, splinting, and exercise should be used to minimize 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. -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. -These areas encompass major joints. Not only does the skin over these areas develop contractures, but underlying tissues, such as the ligaments and tendons, have a tendency to shorten during the healing process. -Because of pain, the patient will prefer to assume a flexed position for comfort. This position predisposes wounds to contracture formation. Positioning, splinting, and exercise should be instituted to minimize this complication. These procedures should be continued until the skin matures. -Therapy is aimed at the extension of body parts because the flexors are stronger than the extensors. Burned legs may be wrapped with elastic (e.g., tensor/Ace) bandages to assist with circulation to leg graft and donor sites before ambulation. This additional pressure prevents blister formation, promotes venous return, and decreases pain and itchiness. Once the skin is completely healed and less fragile, custom-fitted pressure garments replace the elastic bandages.

Hemodynamic Monitoring: Key Terms

1. Stroke Volume (SV)- Amount of blood leaving the left ventricle (LV) during each contraction. Normal: 60-100 mL/ beat. 2. Cardiac Output (CO)- Amount of blood leaving the LV per minute. (HR x SV) Normal: 4-6 L/min. Essential for adequate tissue oxygenation. 3. Cardiac Index (CI)- Is the CO / sq. meter of body surface area. More accurate than CO. Normal: 2.5-3 L/min. 4. Ejection Fraction (EF)- % of blood ejected from the ventricles with each beat. Normal: 55-70% 5. Contractility: Force of the contraction. Frank-Starling Law: bigger the stretch = bigger the contraction. 6. Preload: volume of blood in the ventricle at the end of diastole. 7. Afterload: the resistance/pressure the ventricle must overcome to eject blood during systole.

Acute care

1. Surgery -can go anterior or posterior for surgery sometimes both -may put in plates, screws 2. Methylprednisolone mixed recommendations 3. VTE prophylaxis -prevent VTE with lovenox, heparins, SCDs 4. Vassopressors -phenylephrine or norepinephrine (levophed) to maintain the MAP at greater than 85 to 90 mm Hg to improve perfusion to the spinal cord 5. NGT -don't want to vomit, will strain spinal cord 6. Nutrition 7. Body temp 8. Foley -foley to help reg urine output 9. Prevent pressure injury and stress ulcers 10. Bowel and bladder care -keeping track of bowel movements -laxatives? suppositories?

What is shock?

1. Systemic imbalance between supply & demand 2. State of inadequate blood flow to peripheral tissues 3. Causes life-threatening cellular dysfunction, hypotension, and oliguria 4. Often leads to multi-organ dysfunction and death.

Acute Phase:Nursing and Collaborative Management (pg. 448)

1. Temporary *Allografts* (not own skin, possibly cadaver) are used until the recipient site is ready to accept the *Autograft* (own skin) 2. Appropriate coverage of the Autograft: -Gauze next to the graft followed by middle and outer dressings -Unmeshed sheet grafts used for facial grafts --Grafts are left open. --Complication: Blebs: Blebs prevent the graft from permanently attaching to the wound bed. The evacuation of blebs is best performed by aspiration with a tuberculin syringe and only by those who have received instruction in this specialized skill. -If grafting is necessary, the meshed, split-thickness skin graft may be protected with the same greasy gauze dressings next to the graft, followed by middle and outer dressings. With facial grafts, the unmeshed sheet graft is left open, so it is possible for blebs (serosanguineous exudates) to form between the graft and the recipient bed. 3. Excision and grafting -Eschar is removed down to the 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. -Current therapeutic management of full-thickness burn wounds involves early removal of the necrotic tissue followed by application of split-thickness autograft skin. -This therapy has changed the management and mortality rate of burn patients. In the past, patients with major burns had low rates of survival because healing and wound coverage took so long that the patient usually died of sepsis or malnutrition. Because of current earlier intervention, mortality and morbidity rates have been greatly reduced. -Many patients, especially those with major burns, are taken to the OR for wound excision on day 1 or 2 (resuscitation phase). The wounds are covered with a biological dressing or allograft for temporary coverage until permanent grafting can occur. -Devitalized tissue (eschar) is excised down to the subcutaneous tissue or fascia, depending on the degree of injury. Surgical excision can result in massive blood loss, and blood conservation techniques are used to limit this complication. Topical application of epinephrine or thrombin, application of extremity tourniquets, and application of a new fibrin sealant (Artiss) all work to decrease surgical blood loss. -Once hemostasis has been achieved, a graft is then placed on clean, viable tissue to achieve good adherence. -Whenever possible, the freshly excised wound is covered with autograft (person's own) skin. -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 only a limited amount of unburned skin may be available as donor sites for grafting, and some of that skin may be unsuitable for harvesting. --*Permanent graft* --This procedure is performed in some burn centers as soon as possible after admission on suitable patients. --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 confluent 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. --Because CEA grafts are made only of epidermal cells, meticulous care is required to prevent shearing injury or infection. 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. -Artificial skin --Life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable Integra AlloDerm --it needs to be applied within a few days of admission for greatest success. --As with CEA, it is indicated for use in the treatment of life-threatening, full-thickness or deep partial-thickness burn wounds when conventional autograft is not available or advisable, as in elderly or high-anesthetic-risk patients. It has also been successfully used in reconstructive burn surgery procedures --Any successful artificial skin must replace all functions of the skin and consist of both dermal and epidermal elements. The Integra artificial skin dermal regeneration template is an example of a successful skin replacement system available in burn care today. Its application requires a high degree of skill. --Another currently available dermal replacement is AlloDerm, a cryopreserved allogenic dermis. Human allograft dermis, harvested from cadavers, is decellularized to render it immunogenic and then if freeze-dried. Once thawed, AlloDerm is rehydrated with ultra-thin epidermal autografts immediately before placement on a newly excised wound. --autograft preferred 4. Pain management -Patients experience two kinds of pain. --Continuous background pain: a continuous IV infusion of an opioid will allow for a steady, therapeutic level of medication. If an IV infusion is not present, slow-release twice-a-day opioid medications (e.g., MS Contin) are indicated. Around-the-clock oral analgesics can also be used. Breakthrough doses of pain medication need to be available, regardless of the regimen selected. Anxiolytics, which frequently potentiate analgesics, are also indicated and include lorazepam (Ativan) or midazolam (Versed). --Treatment-induced pain: premedication with an analgesic and an anxiolytic is required via the IV or oral route. For patients with an IV infusion, a potent, short-acting analgesic, such as fentanyl (Sublimaze) is useful. During treatment/activity, small doses should be given to keep the patient as comfortable as possible. -Several drugs in combination --Morphine with haloperidol -Treatment-induced pain managed with potent, short-acting analgesic -Elimination of all the pain is difficult to achieve, and most patients indicate satisfaction with "tolerable" levels of discomfort. Pain management is complex and ever-changing throughout the patient's hospital stay and after discharge. -Nonpharmacologic strategies --Relaxation strategies --Visualization, guided imagery --Hypnosis --Biofeedback --Music therapy --They are not meant to be used exclusively to control pain but may help some patients cope with the painful aspects of care, both in the hospital and after discharge. 5. Physical and occupational therapy -Good time for exercise is during wound cleaning and after when the skin is softer and bulky dressings are removed -Passive and active ROM performed on all joints. The patient with neck burns must sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension. -Splints should be custom-fitted to keep joints in functional position. These must be reexamined frequently to ensure an optimal fit, with no undue pressure that might lead to skin breakdown or nerve damage. -imperative to maintain muscle strength and optimal joint function -pt/ot as soon as pt stable 6. Psychosocial care -Social worker -Nursing staff -Pastoral care

Acute Phase: Pathophysiology -weeks to months

1. The *acute phase begins* when the patient is hemodynamically stable 2. The acute phase is concluded when the burned area is *completely covered by skin grafts*, or when the wounds are healed. 3. Diuresis from fluid mobilization occurs, and the patient is less edematous. 4. Bowel sounds return. 5. Healing begins when WBCs surround the burn wound and phagocytosis occurs. 6. Areas that are full- or partial-thickness burns are more evident than in the emergent phase. 7. The patient may now become aware of the enormity of the situation and may benefit from additional psychosocial support. 8. oral nutrition is the best 9. Necrotic tissue begins to slough. 10. Granulation tissue forms. 11. *Partial-thickness burn* -Once eschar is removed, re-epithelialization begins, wounds heal from the edges. 12. *Full-thickness burn wounds* -require *debridement* and must be covered by skin grafts. 13. Often, healing time and length of hospitalization are decreased by early excision and grafting.

Motor and Sensory effects

1. The American Spinal Injury Association (ASIA) Scale 2. Classify severity of impairment 3. Motor and sensory function 4. Rehabilitation potential

Cardiogenic Shock

1. The result of decreased cardiac output (CO) due to the inability of the heart to pump effectively. 2. Causes -Myocardial infarction (STEMI), cardiomyopathy, myocardial contusion (blunt cardiac injury), myocardial depression (secondary to metabolic problems), ventricular rupture, pulmonary artery embolism 3. Results in: -Inability of the heart to pump effectively -body tries to compensate by vasoconstriction -other organs begin to shut down -body cannot compensate much longer -vital organs begin to shut down

Inhalation injury above the glottis (upper airway)

1. Thermally produced 2. Hot air, steam, or smoke 3. Mucosal burns of oropharynx and larynx -manifested by redness, blistering, and edema -swell when get burnt 4. Mechanical obstruction can occur quickly -True medical emergency 5. Reliable clues to this injury: can be rapid onset -Presence of facial burns -Singed nasal hair -Hoarseness, painful swallowing -Darkened oral and nasal membranes/Carbonaceous sputum (burned saliva) -History of being burned in enclosed space -Clothing burns around chest and neck -Edema may compromise breathing/need ETT

Classification of Burn Injury: Extent of Burn

1. Two commonly used guides for determining the total body surface area -Lund-Browder chart --Considered more accurate because the patient's age, in proportion to relative body-area size, is taken into account. 2. *Rule of nines* -Considered adequate for initial assessment of adult patients -rule of nines just a ball park 3. For irregular- or odd-shaped burns, the patient's hand (including the fingers) is approximately 1% TBSA. 4. The Sage Burn Diagram is a free Internet-based tool that is available for estimating TBSA burned 5. The extent of a burn is often revised after edema has subsided and a demarcation of the zones of injury has occurred. 6. 10%—> donor sites 7. 80%—> not enough healthy skin to cover burn area

Resuscitative Phase: Pathophysiology

1. Usually lasts up to *72 hours* -Primary concerns are onset of hypovolemic shock and edema. -Can begin as early as 20 minutes post burn. 2. Fluid and electrolyte shifts & loss -*Plasma to Interstitial Fluid Shift* -Greatest threat is *hypovolemic/burn shock*, caused by a massive *shift of fluids* out of blood vessels as a result of increased capillary permeability. -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. -cells destroyed, K leaks out-> hyperkalemic -low BP for plasma to interstitial shift-> giving fluid—> edema until 3 days -neurogenic shock only once where BP and HR both down

Drug Therapy

1. Vasopressors: norepinephrine, dopamine, phenylephrine, vasopressin 2. Vasodilators: nitroglycerin, epinephrine, sodium nitroprusside 3. Dobutamine

Acute Phase:Nursing and Collaborative Management wound care

1. Wound care -Daily observation -Assessment -Cleansing -Debridement -Dressing reapplication 2. The goals of wound care are to (1) prevent infection by cleansing and debriding the area of necrotic tissue that would promote bacterial growth, and (2) promote wound re-epithelialization and/or successful skin grafting. 3. Nonsurgical debridement, dressing changes, topical antimicrobial therapy, graft care, and donor site care are performed as often as necessary, depending upon the topical cream or dressing ordered. 4. Should be delayed until a patent airway, adequate circulation, and adequate fluid replacement 5. Multimodal approach-Pain Management -*initially IV opioids*: Morphine, fentanyl, hydromorphone -Then SR (suspended release) and SA (sustained action) PO opioids 6. Sedation - lorazepam, midazolam -sedation and pain medication prior to debridement 7. Cleansing -Can be done in a cart shower, shower, or bed/stretcher by you and by physicians using scissors and forceps 8. Debridement- Loose necrotic skin is removed -May need to be done in the OR -Enzymatic debridement- Speeds up removal of dead tissue from healthy wound bed using enzymes -During debridement, necrotic skin is removed. Releasing escharotomies and fasciotomies can be carried out in the emergent phase, usually in burn centers by burn physicians. Care should be taken to accomplish these procedures as quickly and effectively as possible. 9. Partial-thickness wounds are pink to cherry red and wet and shiny with serous exudate. These wounds may or may not have intact blisters and are painful when touched or exposed to air. 10. Full-thickness wounds will be dry and waxy white to dark brown/black and will have only minor, localized sensation because nerve endings have been destroyed. 11. Patients find the initial wound care to be both physically and psychologically demanding. Your emotional support is invaluable and assists in building an important sense of trust. 12. Shower -Tap water not exceeding 104° F is acceptable. -Once-daily shower -Dressing change in morning and evening -Some of the newer antimicrobial dressings can be left in place from to 3 to 14 days, thereby decreasing the frequency of dressing changes. -These dressings are changed anywhere from every 12 to 24 hours to once every 14 days, depending upon the product. Most burn centers support the concept of moist wound healing and use dressings to cover burned areas, with the exception of the burned face (don't wrap face with gauze) 13. Infection is the most serious threat to further tissue injury. -Source of infection is the patient's own flora. -predominantly from the skin (burned and unburned), respiratory tract, and gastrointestinal (GI) tract. Prevention of cross-contamination from one patient to another is a priority for all members of the health care team. 14. Open method -Burn is covered with a topical antibiotic with no dressing over the wound. Usually facial burns. 15. Multiple dressing changes or closed method -Sterilized gauze dressings are laid over a topical antibiotic. -Dressings may be changed from every 12 to 24 hours to once every 14 days. -wrap fingers separately and ear or else will grow together -limbs extended, if not skin will heal w contraction 16. When open burn wounds are exposed, staff should wear -Disposable hats -Masks -Gowns -Gloves 17. When removing contaminated dressings and washing the dirty wound, you may use non-sterile, disposable gloves. 18. Sterile gloves are used when applying ointments and sterile dressings. 19. In addition, the room must be kept warm (approximately 85° F [29.4° C]. 20. All PPE is removed and new applied before you treat another patient. This is necessary to avoid transmitting organisms from one patient to another—a significant risk, especially when there is more than one patient to a room. 21. Careful hand washing and the use of alcohol hand gel, both inside and outside each patient room, are required to prevent cross-contamination. 22. After the dressing change is completed, the equipment and immediate environment are thoroughly cleaned and disinfected. The use of plastic liners on equipment is helpful in reducing potential contamination of equipment and facilitates cleaning.

pathophysiology of shock

1. inadequate tissue perfusion ->alteration in cardiac fx -> peripheral vascular resistance 2. impaired cellular metabolism (shift from aerobic to anaerobic metabolism) ->impaired O2 use=metabolic acidosis ->imbalance of electrolytes & H2O ->impaired glucose metabolism=insulin resistance 3. multiple organ failure & death

Cryoprecipitate

1. prepared from FFP, with 10-20 mL/bag 2. replacement of clotting factors

responsibilities during a blood transfusion

1. verify 2. monitor 3. assess 4. document

A patient who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95.What is the nurse's best first action? A. Palpate the area over the bladder for distention. B. Place the client in the Trendelenburg position. C. Administer oxygen via a nasal cannula. D. Perform carotid massage.

A.

A patient is to undergo skin grafting with the use of cultured epithelial autografts as skin replacement for full-thickness burns. The nurse explains to the patient that this treatment involves: 1. Shaving a split-thickness layer of the patient's skin to cover the burn wound 2. Growing small specimens of the patient's skin into sheets to use as permanent skin coverage. 3. Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage 4. Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage

Answer: 2 Rationale: Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient's own unburned skin.

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which of the following findings is of most concern to the nurse? 1. Urine output of 35 mL/hr 2. Serum K+ of 4.5 mEq/L 3. Decreased bowel sounds 4. Blood pressure of 86/52 mm Hg.

Answer: 4 Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr; mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg. patient is in shock

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? A. "Blood loss from burned tissue is the most likely cause of hypovolemia" B. "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia" C. "The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces" D. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

Answer: d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

Top 5 reasons to Call a Rapid response!

Chest Pain 1. Cardiac or not? 2. 12 lead EKG: look for flattened or inverted T waves or ST segment elevation or depression 3. Look at the patient 4. Assess: Take a deep breath, palpate, location, other complaints, length of pain, character of pain Increased respiratory distress/O2 sat less than 90% 1. Look at the patient 2. RR 3. HR 4. O2 sat 5. Breath sounds Hypotension 1. Look for 30 points lower than baseline or systolic less than 100 2. Look at patient 3. Check skin 4. Check pulses 5. Check temp 6. Check HR, RR, BP Change in LOC/Neuro status 1. Narcotic over sedation? 2. Signs of a stroke: facial droop, hemiparesis, slurred speech, confusion 3. Cincinnati Pre-Hospital Stroke Scale: facial droop, arm drift, speech Falls 1. Determine mechanism of injury 2. Check LOC 3. Movement of all extremities 4. Numbness, weakness or tingling in any extremity

Resuscitative Phase: Pathophysiology (pg. 437)

Fluid and electrolyte shifts (cont'd) 1. Colloidal osmotic pressure (COP) decreases, resulting in fluid shift: *vascular to interstitial shift.* 2. The net result of the fluid shift is intravascular volume depletion. -*↑ Edema* -*↓ Blood pressure, ↑ Pulse* 3. Normal insensible loss: 30 to 50 mL/hr 4. Severely burned patient: 200 to 400 mL/hr 5. lose lot of fluids cause don't have skin to hold it in 6. RBCs are hemolyzed by a circulating factor (oxygen free radicals) released at the time of the burn, as well as by the direct insult of the burn injury. -impairing the circulatory system 7. Thrombosis in capillaries of burned tissue -causes an additional loss of circulating RBCs 8. *Elevated hematocrit ↑ HCT* (hemoconcentration) -resulting from fluid loss. After fluid balance has been restored, lowered hematocrit levels are found secondary to dilution. 9. Na+ shifts to the interstitial spaces and remains until edema formation ceases. 10. K+ shift develops because injured cells and hemolyzed RBCs release into extracellular spaces. *Hyperkalemia ↑ K+*

Why Blood?

Loss 1. Anemia 2. Hemorrhage 3. Trauma 4. Hypovolemia 5. Shock 6. Surgery 7. Severe gun shot/knife wounds Disease 1. Severe thrombocytopenia -cancer can cause thrombocytopenia making pt candidate for transfusion 2. Hemophilia 3. Sickle Cell Disease

Complications

Systemic Inflammatory Response Syndrome (SIRS) 1. Specific triggers (infection/injury) cause the immune system to activate a cascade system that causes uncontrolled inflammation that overwhelms the body's normal protective mechanisms -Vasodilation -Increased platelet aggregation -Reduced tissue perfusion -Changes in LOC- - can lead to coma and death -Alteration in cardiac output- can lead to myocardial dysfunction and hypoxia, which can lead to dysrhythmias and acute lung injury 2. Management -Initiation of a Sepsis Resuscitation Bundle -Rapid recognition of the source of infection or cause of shock/sepsis -Prevention of additional organ involvement Multiple Organ Dysfunction Syndrome (MODS) 1. A spectrum of organ dysfunction in a patient who has SIRS or septic complications -2 or more organs involved -60-100% mortality rate 2. Management -Rapid recognition of the source of infection or cause of shock/sepsis -Prevention of additional organ involvement