4704 EXAM TWO (Weeks 4-6)

Three Layers of Skin

1. Epidermis: nonvascular outer layer, approximately as thick as sheet of paper, holds in fluids & electrolytes, regulates body temperature, keeps harmful agents from invading the body. 2. Dermis: lies below epidermis, 30 to 45 times thicker than the epidermis. contains connective tissues with blood vessels & highly specialized structures hair follicles, nerve endings, sweat glands, and sebaceous glands 3. Subcutaneous tissue, contains major vascular networks, fat, nerves,& lymphatics, acts as heat insulator for underlying structures, includes muscles, tendons, bones, internal organs.

Types of Burn Injury

1. Thermal burns 2. Chemical burns 3. Smoke inhalation injury 4. Electrical burns 5.Cold thermal injury (frostbite - discussed later in semester)

A mother arrives at an emergency room with her 5-year-old child. The mother states the child fell from a bunk bed. A head injury is suspected, and a nurse is continuously assessing the child for signs of ICP. Which of the following would indicate a late sign of ICP in this child? 1. Bulging fontanel 2. Dilated scalp veins 3. Nausea 4. Widened pulse pressure

4. Widened pulse pressure

Types of Smoke Inhalation Injuries

A. Metabolic asphyxiation B. Upper airway injury C. Lower airway injury

Bacterial Meningitis Complications: Acute cerebral edema

Acute cerebral edema may cause • Seizures • CN III palsy • Bradycardia • Hypertensive coma • Death • Can happen for months after the diagnosis of meningitis

Burns occurence

Although burn incidence has decreased over the past few years, burn injuries still occur too frequently, and most should be viewed as preventable. The highest fatality rates occur in children 4 years of age and younger and in adults over 65.

Severity of electrical burn injury depends on:

Amount of voltage Tissue resistance Current pathways Surface area Duration of flow • Tissue densities offer various amounts of resistance to electric current. • Fat and bone offer the most resistance, Nerves/blood vessels : least resistance. • Current that passes through vital organs will produce more life-threatening sequelae than current that passes through other tissue • Electrical sparks may ignite patient's clothing, causing a combination of thermal flash injury

Escharotomy

An escharotomy (a scalpel or electrocautery incision through the full-thickness eschar) is frequently done after transfer to a burn center to restore circulation to compromised extremities.

Emergent PhaseNursing Management: Eye Care

Antibiotic ointment, need ophthalmology examination, periorbital edema can prevent opening of eyes , frightening the patient, check that patient's eyelashes are not turned inward toward eyeball, provide assurance that swelling is not permanent, artificial tears into the eyes for moisture provides additional comfort.

SCI Nursing Interventions: Impaired Urinary Elimination

Assess: Bladder distention, I/O, PVR (post-void residual urine volume) Interventions • Indwelling catheter to prevent bladder distention (early) • Intermittent catheterization (later) • Fluids—2000 mL/day • Prevent UTIs—cranberry juice?

SCI Nursing Interventions: Acute Pain

Assess: Headache from tongs or pins Intervention: Prescribed pain Rx

SCI Nursing Interventions: Ineffective breathing pattern

Assess: LS, rate & rhythm, use of accessory muscles, stridor, ability to swallow/cough, ABGs, O2 sat, skin color Interventions: • Ventilator management if phrenic nerve damaged (C3 and above) • Risk for VAP (ventilator acquired pneumonia) • Assisted cough, TCDB, suction, O2

SCI Nursing Interventions: Impaired Physical Mobility

Assess: Spasms, skin breakdown, contractures, Interventions: • Antispasmodic meds, pressure reduction devices, PROMs • Botox • Position changes q 2 hours, orthostatic hypotension-move slowly to erect position • Avoid thermal injuries

SCI Nursing Interventions: Constipation

Assess: Usual pattern, BS, distention, diet and fluids Interventions • Bowel program to prevent constipation/impaction • Suppository, mini-enema, digital stimulation, manual extraction • Fluids and fiber • Stool softeners. Bulking agents • Position for evacuation: Sims' position—left-lateral with upper leg flexed toward waist

SCI Nursing Interventions: Ineffective airway clearance

Assess: Vital capacity, ABGs, use of accessory muscles, stridor, sputum—color and consistency, mental status Interventions: • O2, IS, Assisted cough (quad cough), chest physiotherapy, suctioning, trach care, ventilator care, humidity and hydration • Prevent: atelectasis, pneumonia

Burns Rehabilitation Phase

Begins when: • Wounds have healed • Patient is engaging in self-care • Can occur as early as 2 weeks or as long as 7 to 8 months after a major burn injury. Goals for the patient now are to (1) work toward resuming a functional role in society (2) rehabilitate from functional and cosmetic postburn reconstructive surgery

Burns: Acute Phase Begins & Ends With

Begins with: • mobilization of extracellular fluid and • subsequent diuresis Concludes when • Partial thickness wounds are healed and/or • Full thickness burns are covered by skin grafts • This may take weeks or months.

Battle's sign

Bruising behind the ears, indicative of a basilar skull fracture

Burns to the face, neck, chest

Burns to the face and neck and circumferential burns to the chest/back may interfere with breathing as a result of mechanical obstruction secondary to edema or leathery, devitalized burn tissue (eschar). may also signal the possibility of smoke or inhalation injury.

Burns to the hands, feet, joints, eyes

Burns to the hands, feet, joints, and eyes are of concern because they make self-care difficult and may jeopardize future function.

The goals of wound care are to

(1) prevent infection by cleansing /debriding necrotic tissue that would promote bacterial growth, (2) promote wound re-epithelialization and/or successful skin grafting.

SCI: Acute Medical management RESPIRATORY

(Cervical injuries) C4 & above: • Total loss of respiratory function (vent) Below C4: • Diaphragmatic breathing if phrenic nerve functioning • Hypoventilation Cervical and thoracic: • Ineffective cough • Risk for atelectasis and pneumonia

Thermal Burns

Caused by: • Scald: in the bathroom or cooking • Flame, flash,, or contact with hot objects (cooking, hot oil, smoking, gasoline) • Most common type of burn injury Severity of injury depends on: • Temperature of burning agent • Duration of contact time

Brain Injury Pupillary Assessment

Check for size & response

Late signs of increased ICP

Cushing's Triad: • increased systolic blood pressure and widened pulse pressure, • bradycardia, • and irregular respirations • Significant decrease in level of consciousness • Decorticate and decerebrate posturing • Fixed and dilated pupils

Death from Head Injury

Death occurs generally around 48 hours and is usually due to ICP. • Children can come in and be conscious and will die within 48 hours due to increased ICP • Might sedate

Coup-Contrecoup Injury

Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. • Whiplash (brain moves back and forth - back of brain also bruised)

Encephalitis Diagnostic Studies

Early diagnosis and treatment are essential for favorable outcomes • CT • MRI • PET • PCR tests for HSV DNA/RNA • Blood test for West Nile viral RNA

Emergent Phase Nursing Management: Airway management

Early endotracheal intubation • within 1 to 2 hours after burn injury. • Extubation when edema resolves, usually 3 to 6 days after burn injury, unless severe inhalation injury exists. • Escharotomies of the chest wall: to relieve respiratory distress 2° to circumferential, full-thickness burns of the neck and chest. • Fiberoptic bronchoscopy if smoke inhalation (cleans out airway) • Humidified air and 100% oxygen • High Fowler's, CDB, reposition q 1 to 2 hours

Emergent Phase Pathophysiology Fluid and electrolyte shifts

Fluid and electrolyte shifts: • Colloidal osmotic pressure decreases • Fluid shifts out of vascular space into interstitial spaces Fluid and electrolyte shifts • Normal insensible loss: 30 to 50 mL/hr (with breathing and through our skin) • Burned patient: 200 to 400 mL/hr Net result of fluid shift: • Intravascular volume depletion • Edema • ↓ Blood pressure • ↑ Pulse • RBCs are hemolyzed by oxygen free radicals released at time of burn • Thrombosis in capillaries of burned tissue causes additional loss of circulating RBCs. • Elevated hematocrit caused by hemoconcentration due to fluid loss. After fluid balance is restored,hematocrit levels drop.

Emergent Phase Nursing Management: Nutrition

Fluid replacement takes priority over nutritional needs • Early/ aggressive nutritional support ↓complications/mortality,↑ wound healing • Nonintubated patients with a burn of <20% TBSA burn usually be able to eat enough to meet their nutritional needs. • Early enteral feeding, preserves GI function, ↑intestinal blood flow, • Hypermetabolic state proportional to size of wound occurs after a major burn • Resting metabolic expenditure ↑ by 50% to 100% > normal • Core temperature is elevated. Catecholamines, which stimulate catabolism and heat production ↑ • Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. • Early, continuous enteral feeding promotes wound healing • Supplemental vitamins and iron may be given • 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.

SCI Community re-entry / discharge planning

From the beginning • Self-care • Mobility • Home modification • PT/OT • Community resources (Support groups/Home care) • Independent activities: Coping skills

Emergent Phase Pathophysiology Inflammation & Immune System

Inflammation and healing • Neutrophils and monocytes accumulate at site of injury, Fibroblasts and collagen fibrils begin wound repair within first 6 to 12 hours after injury Immune system • Skin barrier is destroyed • Bone marrow is depressed • Circulating levels of immune globulins ↓ • WBCs develop defects

Bacterial Meningitis Clinical Manifestations

Key signs of meningitis • Fever • Severe headache • Nausea, vomiting • Nuchal rigidity Coma associated with poor prognosis • Occurs in 5% to 10% of cases Other symptoms that may be present • Photophobia • ↓ LOC • Rash, petechiae • Signs of ↑ ICP (seizures in 1/3 of cases, worsening headache, vomiting, irritability)

Measurement of Cerebral Oxygenation & Perfusion

LICOX catheter • Measures brain oxygenation and temperature • Placed in healthy white brain matter • Sign above pt bed to notify before turning/moving pt • Don't suction • Aseptic technique Jugular venous bulb catheter • Measures jugular venous oxygen saturation • Placement verified by xray • Measures cerebral oxygen supply and demand

Spinal Cord Injuries: Main goal

Main goal of management of anyone with acute SCI is to reduce the neurological deficits and prevent any further loss of neurologic functions

Waterhouse-Friderichsen syndrome (WFS)

Massive, usually bilateral, hemorrhage into the Adrenal glands caused by severe meningococcemia complication of meningococcal meningitis (petechiae, DIC, circulatory collapse, shock)

Incomplete Spinal Cord Injury

Mixed loss of voluntary motor function and sensory function below the level of injury—losses depend upon which spinal tracts are damaged (degree of injury)

Inflammatory Brain Disorders

Most common inflammatory conditions of the brain and spinal cord: • Brain abscesses • Meningitis • Encephalitis • 10% to 30% mortality rate • Long-term neurologic deficits among survivors • Bacteria, viruses, fungi • Chemicals such as contrast media • Blood in subarachnoid space • CNS infections can occur through the bloodstream as well

SCI: Surgery

Most commonly done for patients with an incomplete SCI or with progressive neurological deterioration. If spinal cord is compressed: • Herniated disc • Blood clot • Stabilize the spine

Burns Acute Phase: Complications

Musculoskeletal system • Decreased ROM & Contractures Gastrointestinal system • Paralytic ileus, Diarrhea • Constipation, Curling's ulcer Endocrine system • ↑ Blood glucose levels • ↑ Insulin production • Hyperglycemia • Infections

Encephalitis Clinical Manifestations

Nonspecific onset: • Fever, headache, nausea, vomiting Signs appear in 2 to 3 days • May vary from minimal alterations in mental status to coma • Any CNS abnormality can occur: Tremors, hemiparesis, seizures, cranial nerve palsies, personality changes, memory impairment

Delirium

Onset: more sudden Causes: pholypharmacy, most often hospitalized older adults. Manifestations: disorganized thinking, difficulty concentrating, hallucinations Testing: Confusion Assessment Method (CAM) Treatment: Antipsychotics to treat symptoms of anxiety, depression, and agitation (Risperidone)

Dementia

Onset: slower onset Causes: neurodegenerative conditions and vascular conditions such as ischemia, brain lesions, Lewy bodies etc. Manifestations: loss of memory, orientation, attention, judgement, language and reasoning. Testing: Mini Mental Status Exam (MMSE), UA, MRI Head, Liver function testing, BUN and Serum Creatinine, Neuropsychologic Testing Treatment: • Cholinesterase inhibitors: Helps to improve memory and cognitive functioning (Donepezil, Galantamine) • NMDA receptor antagonists: To improve learning and memory (Memantine) • Antipsychotics: treat symptoms

AD Nursing Interventions: PDA

P: Prevention • 3 big Bs: bowel, bladder & breakdown of skin • keep bladder empty, prevent UTI, bladder scans, assess UOP, foley draining? • check for impaction, last bm, assess bowel sounds • remove binding devices, reposition q2 hours, assess skin regularly, protect from injury D: Detection • Pts with T6 or higher are at greatest risk • Assess BP (systolic 20-40 > baseline) • Pt reports headache - check BP!!! • Assess for s/s of AD A: Action • MEDICAL EMERGENCY • Call RRT • Position the patient at 90° w/ legs lowered • Assess bp every 2-5 mins • Remove binding devices or clothing • Investigate the 3 b's and correct cause • Start with bladder, then bowel, then skin • Meds (nitropaste, nifedipine)

SCI: Acute Medical management PHARMACOLOGIC

Pain Management (Neuropathic pain at level of injury) • NSAIDS • Opioids • Corticosteroids (rarely used anymore bc hyperglycemia) • Antidepressents • Antiseizure, etc

Bacterial Meningitis Evaluation

Patient will • Demonstrate appropriate cognitive function • Be oriented to person, place, and time • Maintain body temperature within normal range • Report satisfaction with pain control

Burns Acute Phase Nursing Management: Pain Management

Patients experience two kinds of pain 1. Continuous background pain • IV infusion of an opioid (hydromorphone) • slow-release, 2x day oral opioid (MS Contin) 2. Treatment-induced pain • Analgesic &anxiolytic, burn care causes pain. The first line of treatment is pharmacologic (see Table 25-13). • Breakthrough doses of analgesia need to be available, regardless of regimen, Anxiolytics: enhance analgesics, are also indicated and lorazepam/midazolam. • For treatment-induced pain, premedicate with an analgesic and possibly an anxiolytic via the IV or oral route. For patients with an IV, a short-acting analgesic, such as fentanyl (Sublimaze) is often used. • Nonpharmacologic strategies • Elimination of all pain is difficult • Most patients accept a "tolerable" level

Brain injury: Minimize complications of immobility

Protection from self-injury • Judicious use of restraints, sedatives • Seizure precautions • Quiet, non-stimulating environment • Psychologic considerations

SCI Assessment

Respiratory: • Breathing pattern and strength of cough • Lungs auscultated Neurological examination: • Motor and sensory function • Spinal shock Temperature • Hyperthermia • Poikilothermism

Chemical Burns

Result of contact with: • Acids (household cleaners) • Alkalis (oven & drain cleaners) • Things that are outside of the pH of the body • Organic compounds (gasoline) •(Can occur is tissue or eyes) Alkali burns: • hard to manage, adhere, cause protein hydrolysis &liquefaction • Damage continues after neutralized Results in injuries to: •Skin, Eyes •Respiratory system, •Liver and kidney (filters of the body) • Chemical & clothing removed quickly • Tissue destruction may continue up to 72 hours after chemical injury

Classification of Burn Injury: Location of Burn

Severity of burn injury is determined by location of burn wound • Face, neck, chest → respiratory obstruction • Hands, feet, joints, eyes → self-care/rehab • Ears, nose, buttocks, perineum → infection • Circumferential burns of extremities cause circulation problems distal to burn • Patients may also develop compartment syndrome from direct heat damage to the muscles and subsequent edema and/or preburn vascular problems.

SCI: Acute Medical management IMMOBILIZATION

Skeletal traction and external fixation for immobilization of the neck/spinal column Cervical traction: • Skeletal tongs—Crutchfield, Gardner-wells tongs • Check for infection at tong insertion sites Cervical/high thoracic: • Halo vest traction • Check for infection at pin sites-pin care • Check for skin breakdown under vest • Don't move person by holding onto halo ring or bars

Spinal Cord Injury

Spinal cord injury involves damage to: • Neural component of the spinal cord • Vertebral column and/or supporting ligaments • Commonly involve both sensory and motor function • Usual cause is trauma, motor vehicle accidents account for 46% of all cases. Pediatric cases often involve falls or child abuse. • Risk factors are age (younger), gender (male), alcohol or drug abuse

Emergent PhaseNursing Management: Tetanus Immunization

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.

Lund-Browder Chart

The Lund-Browder chart is considered more accurate because the patient's age, in proportion to relative body-area size, is taken into account

Rule of Nines Chart

The Rule of Nines, which is easy to remember, is considered adequate for initial assessment of an adult burn patient

Emergent PhaseNursing Management: Antimicrobial agents

Topical agents • penetrate eschar/inhibit bacterial invasion • Silver-impregnated dressings can be left in place anywhere from 3 to 14 days, Silver sulfadiazine & mafenide acetate also used. Systemic agents • are not used in controlling burn flora •little or no blood supply toburn eschar, delivery of antibiotic to wound is limited. • ↑multiresistant organisms • Sepsis remains leading cause of death,

Complete Spinal Cord Injury

Total loss of both motor & sensory function below level of injury; irreversible • Make up 45% of SCIs (degree of injury)

Classification of Burn Injury: Extent of Burn

Two common guides for determining the total body surface area • Lund-Browder chart: Considered more accurate • Rule of Nines: Used for initial assessment • Irregular- or odd-shaped burns: patient's hand (including the fingers) is approximately 1% TBSA. • Extent of burn revised after edema has subsided

Emergent Phase Complications: Respiratory system

Upper airway burns • Edema formation • Mechanical airway obstruction and asphyxia Lower airway injury • The patient with preexisting respiratory problems is more likely to develop a respiratory infection. • Pneumonia is a common complication of major burns and the leading cause of death in patients with an inhalation injury. • Upper airway distress

Conditions Leading to Burn Shock

With major burn injury, there is ↑capillary permeability. fluid components of blood leak into interstitium, causing edema & a ↓ blood volume. Hematocrit ↑ , blood becomes more viscous. ↓ blood volume and ↑ viscosity produces ↑ peripheral resistance. Burn shock, a type of hypovolemic shock, ensues and, if not corrected, can result in death.

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints LOW SCORE = ALWAYS ASSESS ABCs

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry

c.) Brief neurologic assessment

decorticate vs decerebrate posturing

decorticate: • cerebral cortex dysfunction • abnormal Flexion • sign of damage to the nerve pathway between the brain and spinal cord. • lesion ABOVE midbrain • temp regulation present • better outcome decerebrate: • midbrain dysfunction • abnormal Extension and pronation of the arms and legs • severe injury to the brain is usual cause • lesion BELOW midbrain • temp regulation absent • worse outcome

Emergent PhaseNursing Management: Facial Care

face is highly vascular, ↑ amount of edema, ointments and gauze but not wrapped, to limit pressure on delicate facial structures

Autonomic Dysreflexia

is usually caused when a painful stimulus occurs below the level of spinal cord injury. The stimulus is then mediated through the central nervous system (CNS) and the peripheral nervous system (PNS). Medical Emergency (elevated BP) • Occurs in persons with SC lesions above T6. • Imbalance in reflex sympathetic discharge. • Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (e.g., constipation), stimulation of the skin (pressure ulcer). (IMPORTANT)

The goals of donor site care are to

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

Cerebral Blood Flow (CBF)

the amount of blood in mL passing through 100g of brain tissue per minute.

Cerebral perfusion pressure (CPP)

the pressure needed to ensure blood flow to the brain.

Dermatome Chart

the skin innervated by the sensory division of a particular spinal nerve

Burns

• A burn is an injury to the tissues of the body caused by heat, chemicals, electric current, or radiation. • The resulting effects are influenced by temperature of the burning agent, duration of contact time, and type of tissue that is injured.

Decerebrate

• Abnormal Extension and pronation of the arms and legs. • A severe injury to the brain is the usual cause of decerebrate posture. • Lesion BELOW midbrain

Decorticate

• Abnormal Flexion • Decorticate posture is a sign of damage to the nerve pathway between the brain and spinal cord. • Lesion ABOVE midbrain

Encephalitis

• Acute inflammation of brain • Serious, sometimes fatal disease • Caused by a number of viruses • Some are endemic to specific geographic areas and seasons • Ticks or mosquitoes can transmit epidemic encephalitis • CMV encephalitis is common with AIDS

Bacterial Meningitis

• Acute inflammation of meningeal tissue surrounding brain and spinal cord • Usually occurs in fall, winter, or early spring • Often secondary to viral respiratory disease • Mandatory reporting to CDC • Mortality rate near 100% if untreated • Older adults are more often affected • College students in dorms

Emergent PhaseNursing Management: Grafts

• Allograft or homograft skin • Usually from cadavers • Typically used with newer biosynthetic options • Rarely is enough unburned skin left in major (>50%) burn patient for immediate skin grafting, temporary wound closure methods are needed.

Nursing Diagnoses for TBI

• Altered Cerebral Tissue Perfusion related to increased ICP • Ineffective Breathing pattern related to increased ICP or brain stem injury. • Altered nutrition: Less than body requirements related to compromised neurologic function and stress of injury • Altered thought processes related to physiology of injury

Clinical signs of Brain Injury

• Altered level of consciousness • Confusion • Pupillary abnormalities • Alter or absent gag reflex • Absent corneal reflex • Sudden onset of neurologic deficits • Changes in vital signs • Vision and/or hearing deficits • Sensory dysfunction • Spasticity • Headache • Vertigo • Seizures

Emergent PhaseNursing Management: Meds

• Analgesics and sedatives: Morphine, Hydromorphone, Haloperidol , Lorazepam, Midazolam • Pain level may not directly correlate with extent /depth of burn. Analgesic needs can vary from one patient to another, consider a multimodal approach to pain control. • Sedative/hypnotics and antidepressant agents can also be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience.

Brain Abscess Treatment

• Antimicrobial therapy • Symptomatic treatment for other manifestations • Abscess may need to be drained or removed if drug therapy is not effective

Bacterial Meningitis Interprofessional Care

• Bacterial meningitis is a medical emergency • Rapid diagnosis crucial • Patient usually critical when health care is initiated • Antibiotic therapy instituted before diagnosis is confirmed

Burns Acute Phase Nursing Management: PT and OT

• Best time for exercise: during/after wound cleansing, skin is softer, bulky dressings removed, Passive and active ROM all joints. • Maintain occupational therapy schedule for custom-fitted splints, designed to keep joints in functional position. • Check the splints often to ensure an optimal fit, with no undue pressure that might lead to skin breakdown or nerve damage.

Upper airway injury: clinical manifestations

• Blisters, edema • Copious secretions • Difficulty swallowing • Stridor • Hoarseness • Substernal and intercostal retractions • Total airway obstruction

Bacterial Meningitis: Diagnostic Studies

• Blood culture (RIGHT away -start antibiotics before come back) • CT scan • Neutrophils are predominant WBC in CSF • X-rays of skull • CT scans (ICP, hydrocephalus) • MRI Diagnosis verified: • Lumbar puncture (AFTER CT ruled out obstruction) • Analysis of CSF • Specimens of secretions are cultured to identify causative organism • Gram-stain to detect bacteria

Burn Wound Treatment: Open Method

• Burn is covered with topical antibiotic with no dressing over wound • Usually limited to the care of facial burns

Burns Rehabilitation Phase: Pathophysiologic Changes

• Burn wound heals either by spontaneous reepithelialization or by skin grafting • Layers of keratinocytes begin to rebuild the tissue structure • Collagen fibers, present in the new scar tissue, assist with healing, and add strength to weakened areas. • The new skin appears flat and pink. • 4 to 6 weeks, area becomes raised and hyperemic, need ROM so tissue will not shorten to contracture. • Mature healing: reached about 12 months, suppleness returns, pink or red color fades to lighter hue than surrounding unburned tissue. • Skin never completely regains original color • cosmetic camouflage: implantation of pigment can help even out skin tones • Scarring two components: discoloration fade with time, develop altered contours; no longer flat/ slightly raised, elevated & enlarged above burned area. • Gentle pressure maintained on healed burn with custom-fitted pressure garments/clear, thermoplastic face masks, never worn over unhealed wounds, removed for short periods. • Itching where healing is occurring: Massage oil, silicone gel sheeting, gabapentin, injectable steroids also may be helpful. • Healed burn areas protected from sunlight for 3 months: prevent hyperpigmentation / sunburn

Classification of Burn Injury: Depth of Burn

• Burns have been defined by degrees (first, second, third, and fourth) • ABA advocates categorizing burn according to depth of skin destruction: Partial-thickness burn/Full-thickness burn • Skin-reproducing (re-epithelializing) cells located in the dermis and along shafts of hair follicles/sebaceous glands. • If significant damage to the dermis occurs (a full-thickness burn)remaining skin cells insufficient to regenerate skin. • Permanent, alternative source of skin needs to be found. • Superficial partial-thickness burn: Involves epidermis • Deep partial-thickness burn: Involves dermis • Full-thickness burn: Involves all skin elements, nerve endings, fat, muscle, bone

Burns to the ears, nose, buttocks, perineum

• Burns to the ears and the nose are at risk for infection as the skin is very thin and the underlying skeleton is frequently exposed. • Burns to the buttocks or perineum are at high risk for infection from urine or feces contamination.

Brain Injury Diagnostic Studies

• CT scan / MRI / PET • EEG • Cerebral angiography • ICP and brain tissue oxygenation measurement (LICOX catheter) • Doppler and evoked potential studies • NO lumbar puncture (would increase ICP)

Burns Acute Phase Nursing Management: Nutrition

• Caloric needs calculated by dietitian • High-protein, high-carbohydrate foods • Open wounds: Hypermetabolic/ highly catabolic state. • Antioxidant protocol: selenium, vitamin C & E, zinc, multivitamin. • Monitor laboratory values: albumin, prealbumin, total protein, transferrin) • Weight loss not more than 10% of preburn weight. • Record patient's daily caloric intake using calorie count sheets, which are reviewed by the dietitian. • Weigh your patient weekly to evaluate progress.

Incomplete SCI: Anterior cord syndrome

• Can be caused by an acute disc herniation or hyperflexion injury with fracture or dislocation of vertebrae • Can result in an injury of the anterior spinal artery which supplies the blood to the anterior 2/3rds of the spinal cord • Deficits can include: loss of pain, temp, motor function (below site of injury) • Light touch, vibration, position sensation usually remain intact

Spinal shock (Areflexia)

• Can begin within one hour of injury • A sudden depression of reflex activity below the level of spinal injury • Temporary condition with loss of reflexes, sensation, bowel and bladder dysfunction, and flaccid paralysis below the level of injury • Paralytic ileus-NG tube • Usually lasts for hours to weeks - then REFLEX activity and spasticity returns (involuntary)

Measurement of ICP

• Can control ICP by removing CSF (with the ventricular catheter) • Intermittent or continuous drainage • Careful monitoring of volume of CSF drained is essential • Prevent infection and other complications • Ventriculostomy

Brain Herniation

• Can happen as a result if ICP is too high for too long - pt will expire

Emergent Phase Pathophysiology Third Spacing

• Capillary walls become permeable, H2O, Na, and plasma proteins (albumin) move into interstitial spaces Colloidal osmotic pressure ↓ with loss of protein from vascular space. Fluid shifts out of vascular space into the interstitial spaces. • 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.

Neurogenic Shock

• Caused by the loss of function of the autonomic nervous system • Causes cardiovascular changes - hypotension and bradycardia • Loss of vasomotor tone with vasodilatation below injury, venous pooling, decreased cardiac output, & warm, dry extremities • In cervical and upper thoracic spinal cord injuries-respiratory insufficiency • Paralyzed portions of the body do not perspire • Bradycardia and hypotension may continue after shock resolves Treatment of neurogenic shock • Norepinephrine (Levophed)-hypotension • Atropine-bradycardia

Prehospital Care: Large Thermal Burns

• Circulation: Check for pulses, ↑ burned limb(s) above heart to ↓ pain / swelling. • Airway: Check for patency, soot around nares/on the tongue, singed nasal hair, darkened oral or nasal membranes. • Breathing: Check for adequacy of ventilation. • Cool burns for no more than 10 minutes to prevent hypothermia • Do not immerse in cool water or use ice, may cause extensive heat loss and vasoconstriction of blood vessels, reducing blood flow to the injury. • Remove burned clothing • Wrap in clean, dry sheet or blanket to prevent further contamination of the wound and to provide warmth.

Bacterial Meningitis Nursing Implementation: Acute Care

• Close observation and assessment: VS, neuro status, fluid I/O, skin, lungs • Provide relief for head and neck pain • Position for comfort • Darkened room and cool cloth over eyes for photophobia • Seizure precautions • Family at bedside (calming not anxious) • Minimize environmental stimuli (mental distortion & hypersensitivity) • Convey caring and unhurried gentleness while providing efficient care • Provide safety • Observe and record seizures: Prevent injury & administer antiseizure medications • Vigorously manage fever • Assess for dehydration (evaluate I/O; compensate for diaphoresis in replacement fluids) • Maintain therapeutic blood levels of antibiotics • Respiratory isolation until cultures are negative • Calculate replacement fluids for respiratory losses • Supplemental feeding

Brain Stem Contusion

• Commonly associated with auto and sports accidents • Mild cognitive impairment to coma • Brain stem regulates heart rate, respiration, motor skills. • Severe injuries can result in coma or persistent vegetative state • Loss of consciousness

Types of brain injuries

• Concussion • Cerebral contusion • Brain stem contusion • Epidural hematoma • Subdural hematoma • Skull fracture

Burns Acute Phase Nursing Management: Wound Care

• Consists of ongoing observation, assessment, cleansing, debridement, and dressing reapplication. • Nonsurgical debridement, dressing changes, topical antimicrobial therapy, graft care, and donor site care are performed as often as necessary, depending on the topical cream or dressing ordered • Enzymatic debridement: speeds up removal of dead tissue from wound bed • Wounds cleansed with soap /water /NS-gauze to remove antimicrobial agent & loose necrotic tissue, scabs, or dried blood. Covered with topical antimicrobial creams: silver sulfadiazine, silver-impregnated dressings). • After debridement, a protective, coarse or fine-meshed, grease-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. • Gauze next to graft followed by middle and outer dressings • Unmeshed sheet grafts used for facial grafts: Grafts are left open

Prehospital Care: Small Thermal Burns

• Cover with clean, cool, tap water—dampened towel, Cooling of the injured area (if small) within 1 minute helps minimize the depth of the injury.

Bacterial Meningitis Nursing Diagnoses

• Decreased intracranial adaptive capacity • Risk for ineffective cerebral tissue perfusion • Hyperthermia • Acute pain

Burn Unit Referral Criteria

• Deep Partial Thickness burns>10% TBSA • Burns that involve the face, hands, feet, genitalia, perineum, or major joints • Full thickness burns in any age group • Electrical burns, including lightning • Inhalation burns requiring intubation • Chemical burns that involve deep and extensive TBSA burned

SCI: Risk for Venous thromboembolism (VTE)

• Deep venous thromboembolism (DVT) • Pulmonary embolism (PE) • Anti-embolism stockings • Pneumatic compression devices • Low-dose anticoagulation therapy • Vena cava filters • Never massage calves of pt who is immobile bc don't want to dislodge something that might be there

Emergent PhaseNursing Management: Wound care

• Delayed until patent airway, adequate circulation & fluid replacement • Cleansing and gentle debridement: using scissors and forceps, can occur on a shower cart, in a regular shower, or on a patient bed/stretcher • Extensive surgical debridement is done in the operating room, necrotic skin is removed. • Releasing escharotomies /fasciotomies are done in emergent phase by burn physicians. • First wound care is physically/mentally demanding. Need emotional support

Severity of burn injury is determined by

• Depth of burn • Extent of burn in percent of TBSA • Location of burn The majority of patients with minor burn injuries can be managed in community hospitals.

Medications R/T Head injuries: Decadron

• Dexamethasone • steroid that treats inflammation • CONTROVERSIAL

Viral Meningitis Diagnosis

• Diagnostic testing of CSF • Rapid diagnosis with Xpert EV test • Sample of CSF is evaluated for enterovirus • CSF can be clear or cloudy • Typical finding is lymphocytosis • Results available within hours • PCR to detect viral-specific DNA/RNA

Early signs of increased ICP

• Disturbances in consciousness: confusion to coma • Headache, vertigo • Agitation, restlessness • Respiratory irregularities • Cognitive deficits • Pupillary abnormalities • Sudden onset of neurologic deficit • Infants may have a bulging fontanel, wide sutures, increased head circumference; dilated scalp veins, high pitched cry

Burns Acute Phase: Pathophysiology

• Diuresis from fluid mobilization occurs, and patient is less edematous • Bowel sounds return (can use for nutrition) • Healing begins as WBCs surround burn wound and phagocytosis occurs • Depth of burn wounds may be more apparent as they "declare" themselves as partial- or full-thickness. Can see more and measure more. • Patient may become aware of enormity of the situation and will benefit from emotional support and information • Necrotic tissue begins to slough • Granulation tissue forms • Partial-thickness burn wounds heal from edges and from dermal bed • Full-thickness burns must have eschar removed and skin grafts applied • Often, healing time and length of hospitalization are decreased by early excision and grafting.

Medications R/T Head injuries: Furosemide

• Diuretic • Anticipate urine output

Emergent Phase Complications: Cardiovascular system

• Dysrhythmias and hypovolemic shock • Circulation to the extremities can be severely impaired by deep circumferential burns and subsequent edema formation, which act like a tourniquet. If untreated, ischemia, paresthesias, and necrosis can occur. • Impaired microcirculation/↑ viscosity → sludging: damage to skin structures that contain small capillary systems • Venous thromboembolism (VTE) • Circumferential could lead to loss of extremity

Emergent PhaseNursing Management: Positioning

• Ears should be kept free of pressure • No use of pillows, may cause chondritis, ear may stick to the pillowcase, causing pain /bleeding. Hands/arms extended and elevated • pillows /foam wedges to minimize edema, splints for functional position Raise patient's head • using a rolled towel placed under the shoulders, to avoid pressure necrosis. • Pillows are removed and a rolled towel is placed under the shoulders to hyperextend the neck and prevent neck contraction. • Early ROM exercises: PT

Interventions to optimize ICP and CPP (cerebral perfusion)

• Elevate HOB • Prevent extreme neck flexion • Slowly turn the patient • Avoid coughing, straining, Valsalva • Avoid hip flexion

Phases of Burn Management

• Emergent (resuscitative) • Acute (wound healing) • Rehabilitative (restorative) • An overlap exists from one phase to another. • Emergent phase begins in emergency department or prehospital phase, depending on the skill level of paramedics at the scene. • Planning for rehabilitation begins on day of burn injury or admission to the burn center. • Formal rehabilitation begins as soon as functional assessments can be performed. • Wound care is primary focus of acute phase,also takes place in emergent rehabilitative phases.

Burns: Emergent Phase

• Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury • Up to 72 hours • Primary concerns: Hypovolemic shock & Edema • The emergent phase ends when fluid mobilization and diuresis begin. • Greatest threat is hypovolemic shock • Caused by a massive shift of fluids out of blood vessels as a result of increased capillary permeability • Can begin as early as 20 minutes post burn.

Autonomic Dysreflexia Rapid assessment to identify and eliminate cause

• Empty the bladder using a urinary catheter or irrigate or change indwelling catheter • CHECK cath for kinks • Examine rectum for fecal mass • Examine skin • Examine for any other stimulus

Actions for Head Injuries

• Evaluate level of consciousness • Complete a neurological assessment • Careful Intake and Output (avoid over hydration) • Seizure precautions • Elevate the HOB 30 degrees • Prevent infection of open wounds • Manage increased intracranial pressure (ICP) • Hypothermia (keep cool and not feverish) • Minimal procedures (turning, etc) • Prevent complications (pressure ulcers)

Nursing Assessment of Cranial Nerves

• Eye movement (3, 4, 6) • Corneal reflex (5, 7) - if absent provide eye care • Oculocephalic reflex (doll's eye reflex) • Oculovestibular (caloric stimulation)

Bacterial Meningitis Nursing Implementation: Vigorously manage fever

• Fever increases cerebral edema and the frequency of seizures • Don't reduce temp of body too fast • Neurologic damage may result from high, prolonged fever • Wrap extremities in soft towels or blanket • Want to prevent shivering • Cooling blanket for fever

SCI: Emergency Management

• Goal to maintain life and function At scene of accident: (imperative) • Avoid flexing/extending neck • Stabilize neck (neck brace) • Maintain in supine position (immobilize on back board) • Danger of death is greatest when there is injury to the upper cervical region • C1-C4 - respiratory paralysis - requires mechanical ventilation • Must account for ascending spinal cord edema • Anyone who has sustained trauma to the head and the spine is at risk for SCI: UNTIL RULED OUT

Other signs to look for with head injury

• Hemotympanum (ear) • Septal hematoma (nose) - Can result in septal necrosis

Lower Airway Injury Clinical Manifestations

• High degree of suspicion if patient was trapped in a fire in an enclosed space or clothing caught fire • Altered mental status • Carbonaceous sputum • Dyspnea • Facial burns or singed nasal or facial hair • Hoarseness • Wheezing • Darkened oral and nasal membranes • History of being burned in an enclosed space • Clothing burns around the neck and chest.

SCI: Assessment and Diagnostic Procedures

• History of event (what happened) • Physical assessment—Neuro checks, motor strength, sensation • Spinal x-rays • CT and/or MRI • Myelogram (only if indicated)

SCI Nursing role in Rehabilitation

• Holistic approach: Advocate, listen, provide support & encouragement, discharge planning • Teach and reinforce teaching • Implement and reinforce therapy approaches • Maintain body function: B/B, respiratory, cardiac • Prevent complications: DVTs, contractures, pneumonia, skin breakdown, UTIs, bowel problems

Burns Acute Phase: Potassium Lab Values

• Hyperkalemia may occur if patient has: Renal failure, adrenocortical insufficiency, massive deep muscle injury • Large amounts of potassium is released from damaged cells • Hyperkalemia can cause: Heart dysrhythmias and ventricular failure, Muscle weakness, ECG changes •Hypokalemia occurs with: Vomiting, diarrhea, Prolonged GI suction, Lengthy IV therapy without potassium • Signs and symptoms of hypokalemia include fatigue, muscle weakness, leg cramps, heart dysrhythmias, paresthesias, and decreased reflexes

Burns Acute Phase: Sodium Lab Values

• Hyponatremia can develop from: Excessive GI suction/Diarrhea • Manifestations include: weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, confusion. • Water intoxication( dilutional ↓ Na): offer fluids other than water, such as juice, soft drinks, nutritional supplements • Hypernatremia may develop following: uccessful fluid replacement, improper tube feedings, inappropriate fluid administration • Manifestations of hypernatremia include thirst; dried, furry tongue; lethargy; confusion; and possibly seizures. • Restrict sodium in IVs, oral feedings

SCI orthostatic hypotension

• Hypotension for those with injuries above T7. • BP tends to be unstable and low for first two weeks (trauma to ANS) • Gradually returns to normal Interventions: • Monitor VS before and after position change • Vasopressor medication-Norepinephrine (Levophed) • Anti-embolism stockings

SCI: Intensive Care Unit

• Immobilization is important to prevent further injury • Traction • Maintain a stable blood pressure (vasopressors to maintain MAP) • Monitor cardiovascular function • Ensure adequate ventilation of lung function • Prevent and promptly treat infection and other complications

SCI Nursing Goals

• Improved breathing pattern and airway clearance • Improved mobility • Prevention of injury due to sensory impairment • Maintenance of skin integrity • Relief of urinary retention • Improved bowel function • Decreasing pain

SCI: Nursing Diagnoses

• Ineffective breathing pattern • Ineffective airway clearance • Impaired physical mobility • Risk for impaired skin integrity • Impaired urinary elimination • Constipation • Acute pain

Complications of TBI

• Infections • Increased ICP, hydrocephalus • Postraumatic seizure disorder • Permanent neurologic deficits • Neurobehavioral alterations

Smoke Inhalation Injuries

• Inhalation of hot air/noxious chemicals • damage to tissues of respiratory tract • Cause damage to respiratory tract • Major predictor of mortality in victims • Rapid initial assessment is critical. • Assess for airway compromise and pulmonary edema that can develop over the first 12-48 hours. • Need to be treated quickly • House fires • Breathing in hot air/noxious chemicals • Prepare for intubation and resp support • Look in mouth/nares

Bacterial Meningitis Nursing Assessment

• Initial assessment should include • Vital signs • Neurologic assessment • Fluid intake and output • Evaluation of lungs and skin

Effects of Burn Shock

• Injured cells & hemolyzed RBCs shift K+ to extracellular spaces • Na+ moves to interstitial spaces, edema formation ends • Capillary membrane permeability is restored if fluid replacement is adequate. • Interstitial fluid gradually returns to vascular space. • Diuresis occurs, and the urine has a low specific gravity. • Potassium moves out; sodium moves in

Upper airway injury

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

Lower Airway Injury

• Injury to trachea, bronchioles, and alveoli • Injury is related to length of exposure to smoke or toxic fumes • Pulmonary edema may not appear until 12 to 48 hours after burn • Manifests as acute respiratory distress syndrome (ARDS)

SCI Nursing Interventions: Risk for Impaired Skin Integrity

• Inspect skin daily and observe pressure points • Change position q 2 hours • Use pressure reduction devices • Cushions • Mattresses • Keep skin clean, dry and intact

Burns Rehabilitation Phase: Wound Care

• Involve patient/caregiver • May go home with unhealed wounds Before discharge: • Patient demonstrate dressing change. • When to contact burn team: signs of infection, ↑pain) • home care nursing services to assist with care. • Water-based creams penetrate into dermis used on healed areas skin supple, ↓ itching/flaking. • Oral antihistamines at bedtime if itching persists.

Emergent PhaseNursing Management: VTE Prophylaxis

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

TBI Nursing Interventions: Maintain adequate cerebral perfusion

• Maintain a patent airway • Monitor ICP • Monitor for changes in neurologic status • Identify emerging trends and communicate to medical staff. • Monitor response to pharmacologic therapy including drug levels. • Monitor laboratory data • Monitor results of serial serum and urine electrolyte and osmolality studies • Assess dressings and drainage tubes • Institute measures to minimize IICP • Prepare to administer medications such as dexamethasone and/or mannitol

Management of TBI

• Management of ICP • Maintain a patent airway. • Balance of fluid and electrolytes. • Antibiotics to prevent infection • Osmotic diuretic (Mannitol) • Control of pain and fever per ordered medications. • Surgery for evacuation of hematomas, debridement of penetrating wounds, elevation of skull fractures or repair CSF leaks. • Space out activities • DO NOT SUCTION THROUGH NOSE (could cause secondary infection in brain)

Burns Acute Phase Nursing Management: Excision & Grafting

• Management of full-thickness burn wounds involves early removal of necrotic tissue followed by application of split-thickness autograft skin. • Patients with major burns, taken to OR for wound excision on day 1 or 2,wounds covered with biological dressing or allograft for temporary coverage until permanent grafting can occur, excised down to the subcutaneous tissue fascia, can result in massive blood loss. Topical epinephrine or thrombin, extremity tourniquets, new fibrin sealant work to decrease surgical blood loss. • Whenever possible, the freshly excised wound is covered with autograft (person's own) skin. • Grafts are attached with: Fibrin sealant, Sutures or staples • Negative pressure wound therapy • Early excision restores function, ↓scar tissue • Frequent observation for bleeding/circulation problems help identify/manage complications that would interfere with graft survival.

Upper airway distress:

• May occur with the absence of burn injury to the skin. • Fiberoptic bronchoscopy carboxyhemoglobin blood levels • Examine sputum for carbon. • Signs: ↑ agitation, anxiety, restlessness, or a change in the rate or character of the patient's breathing as symptoms may not be present immediately.

Carbon monoxide (CO) poisoning

• Metabolic asphyxiation • Hypoxia and ultimately death when CO levels are 20% or greater • Treat with 100% humidified oxygen • CO poisoning may occur in absence of burn injury to skin

Head Injury Classifications: Mild, Moderate & Severe

• Mild (GCS 13 to 15 with loc to 15 minutes) • Moderate (GSC 9 to 12 with loc for up to 6 hrs) • Severe (GSC 3 to 8 with loc > 6 hours)

TBI Nursing Assessment

• Monitor for signs of ICP • Observe for CSF leakage • Note contusions about the eyes & ears. • Perform cranial nerve, motor, sensory, and reflex assessments. • Assess for behavior that warrants potential for injury to self or others.

TBI Nursing Interventions: Maintain Respiration

• Monitor respiratory rate • Assist with intubation and ventilatory assistance if needed • Turn patient Q 2 hours & assist with cough and deep breathing. • Suction patient as needed (NOT through nose)

ICP Regulation and Maintenance

• Monro-Kellie doctrine • If one component increases, another must decrease to maintain ICP • Through autoregulatoin • Normal ICP 5 to 15 mm Hg • Elevated if >20 mm Hg and sustained

Cerebral Contusion

• More severe injury-brain bruise • Unconsciousness • Can result in subdural collections of blood • Signs and symptoms depend on the extent of the injury

Encephalitis Interprofessional Management

• Mosquito control for prevention • Draining bird baths, clean rain water out of pots, etc • Nursing management is symptomatic and supportive • Intensive care may be required • Acyclovir (preferred less SE), vidarabine for encephalitis from HSV infection • Reduce mortality rates • May not reduce neurologic complications • Start treatment before onset of coma • Antiseizure drugs for seizures: May be initiated prophylactically

Viral Meningitis

• Most common causes are enterovirus, arbovirus, HIV, and HSV • Most often spread through direct contact with respiratory secretions • Usually presents as headache, fever, photophobia, and stiff neck • Fever may be moderate or high

Burns Rehabilitation Phase: Skin & Joint Contractures

• Most common complications during rehab • Positioning, splinting, exercise minimize • Maintain functional position of joints with splints • Areas most susceptible: Anterior/lateral neck areas, axillae, antecubital fossae, fingers, groin areas, popliteal fossae, knees, and ankles • Therapy aimed at extension of body parts, flexors are stronger than the extensors.

Ventriculostomy in Place

• Most common to monitor ICP

SCI Rehab

• Multidisciplinary approach • Begins immediately • Continues after discharge from acute care • Goal: achievement of optimal level of functioning in all aspects of life

Burns Rehabilitation Phase: Emotional Needs

• Need encouragement and reassurance to maintain morale, recovery can be slow. Rehabilitation may need to be a primary focus for at least the next 6 to 12 months. • Essential patients be encouraged to discuss 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. • Assess circumstances of burn injury • Burn survivors often experience anxiety, guilt, and depression • Nurses have important supportive/ counseling role as patients struggle to get their lives back on track. • New fears (can I really do this?) • Fear of loss of relationships from disfigurement, alterations in body image can result in psychologic distress. • Need open and frequent communication among the patient, caregivers, close friends, and burn team members (care conferences) • Sexuality issues must be met with honesty. changes in processing sexual stimuli immature scar tissue may make the sensation of touch unpleasant

Secondary Spinal Cord Injury

• Nerve fibers begin to swell and disintegrate. • Ischemia, hypoxia, edema, and hemorrhage begins within a few hours, within 24 hours the function of the nerves passing through the area of injury is lost. • Edema extends the level of the injury and for two cord segments above and below the affected level. (C3 injury: can go from C1-C5) • Can results in irreversible damage CRITICAL

Intracranial Pressure (ICP)

• Normal Intracranial pressure ranges from 5 to 15 mm Hg. • ICP can be monitored by means of an intraventricular catheter, a subarachnoid screw or bolt, or an epidural pressure-recording device. • A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. • Early signs of an INCREASE in ICP (IICP) are headache, pupillary abnormalities • An increase in ICP is a life-threatening complication - can lead to permanent neuro-dysfunction or death if not caught early • CSF/Brain/Blood: When one is thrown out of proportion the ICP will change

Pregnancy and Labor and Autonomic Dysreflexia (AD)

• Often misdiagnosed as pre-eclampsia • S/S of AD occurs with contractions • Experience no pain-anesthesia should still be used • Outcomes of AD: Unpleasant symptoms to hypertensive encephalopathy, cerebral vascular accidents, intraventricular and retinal hemorrhages, and death

Emergent PhaseNursing Management: Hygiene

• Once-daily shower • Dressing change in morning and evening • Some newer antimicrobial dressings can be left in place longer (less dressing changes) • Infection is most serious threat to further tissue injury • Source of infection is patient's own flora from skin/respiratory /GI tract. • Perineum must be kept clean and dry (catheter, fecal tube, peri care 1-2x daily)

Bacterial Meningitis: Etiology and Pathophysiology

• Organisms enter CNS through upper respiratory tract or bloodstream • May enter through skull wounds or fractured sinuses • Often secondary to viral respiratory disease • Mandatory reporting to CDC • Mortality rate near 100% if untreated • Older adults most often affected Inflammatory response • ↑ CSF production • Purulent secretions spread to other areas of brain through CSF • Cerebral edema and increased ICP become problematic • If process extends into parenchyma • If concurrent encephalitis is present

Burns Acute Phase: Infections

• Partial-thickness burns can change to full-thickness wounds with infection • Burn injury destroys body's first line of defense, the skin. • If levels of bacteria between eschar and viable wound bed rise to > than 105/g of tissue, patient has a burn wound infection. • Wound infections may be treated with systemic antibiotics based on wound culture results.

Burns Acute Phase: Clinical Manifestations

• Partial-thickness wounds form eschar: once eschar is removed, reepithelialization begins • Full-thickness wounds require debridement • Epithelial buds from the dermal bed eventually close in the wound, which then heals spontaneously without surgical intervention, usually within 10 to 21 days. • Margins of full-thickness eschar take longer to separate. Full-thickness wounds require surgical debridement and skin grafting for healing.

Classification of Burn Injury: Patient Risk Factors

• 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. • Patient with diabetes mellitus or peripheral vascular disease is at high risk for poor healing and gangrene, especially with foot and leg burns • Physical weakness renders patient less able to recover: alcoholism, drug abuse, malnutrition • Concurrent fractures, head injuries, or other trauma leads to a more difficult time recovering

Autonomic Dysreflexia Nursing Interventions

• Place patient in seated position to lower BP (Elevate HOB) • Administer IV diazoxide (Hyperstat), nifedipine, hydralazine • Remove TEDs, sequential compression devices • Label chart or medical record that patient is at risk for autonomic dysreflexia • Instruct patient in prevention and management

Bacterial Meningitis Nursing Implementation: Ambulatory Care

• Provide for several weeks of convalescence • Increase activity as tolerated • Stress adequate nutrition • High protein/high calorie meals • Small frequent meals • Encourage adequate rest and sleep • Progressive ROM exercises and warm baths for muscle rigidity • Ongoing assessment for recovery of vision, hearing, cognitive skills, motor and sensory abilities • Tend to signs of anxiety and stress of family and caregivers

TBI Nursing Interventions: Meet Nutritional Needs

• Provide nasogastric feedings • Consult with a dietician to provide increased calories and nitrogen • Administer IV hyperalimentation as ordered • During rehabilitation, recognize the dysphagic patient • Speech therapy for swallowing difficulties • Elevate HOB after feedings • Check for residuals • H2 blocking agent to prevent ulcers

Brain Abscess

• Pus within brain tissue • Results from a local or systemic infection • Direct extension from an ear, tooth, mastoid or sinus infection • Pulmonary infection, bacterial endocarditis, skull fractures, brain trauma, surgical wound Primary infective organisms • Streptococci • Staphylococcus aureus

Prehospital Care: Electrical Injuries

• Remove patient from contact with source

Electrical Burns

• Result from coagulation necrosis caused by intense heat generated from an electric current • May result from direct damage to nerves and vessels, causing tissue anoxia and death • Severity of injury depends on: Amount of voltage, Tissue resistance, Current pathways, Surface area, Duration of flow • Severity of injury difficult to assess bc most damage occurs beneath skin ("Iceberg effect") • Current may cause muscle spasms strong enough to fracture bones • Rapid assessment must be performed. • Transfer to a burn center is indicated. • Contact may reveal the path of the current and potential areas of injury. • Patients are at risk for: dysrhythmias or cardiac arrest (can occur without warning during first 24 hours after injury) • Patients are at risk for: acute tubular necrosis and AKI: myoglobin and hemoglobin from damaged RBCs travel to kidneys

Primary Spinal Cord Injury

• Result of initial insult or trauma • Permanent damage • Occurs at the time of injury • Whatever the effects are that part is permanent

Bacterial Meningitis Planning: Overall Goals

• Return to maximal neurologic functioning • Resolve the infection • Control pain and discomfort

Autonomic Dysreflexia Symptoms

• Severe pounding headache. • Extremely high bp • A slow heart rate (bradycardia) • Nasal stuffiness. • Nausea. ABOVE LEVEL OF SPINAL INJURY: • A flushed face and/or red blotches on the skin • Sweating (bc vasoconstriction) BELOW LEVEL OF SPINAL INJURY: • Goose bumps (piloerection) • Cold, clammy skin

TBI neurologic deficits result from

• Shearing of white matter • Ischemia • Hemorrhage • Cerebral edema

Emergent Phase Clinical Manifestations

• Shock from hypovolemia • Blisters filled with fluid & protein with partial thickness burns • Paralytic ileus with large burns, no BS • Shivering: heat loss, anxiety, pain • Full-thickness /deep partial-thickness burns are at first painless because the nerve endings are destroyed. • Superficial to moderate partial-thickness burns are very painful. • Decreased bp and tissue perfusion

Manifestations of brain abscess

• Similar to meningitis and encephalitis • Headache • Fever • Nausea and vomiting • Signs of increased ICP: Drowsiness, Confusion, Seizures • Symptoms reflect local area of abscess (headache on side of abscess • Focal symptoms: visual deficit, seizures, hallucinations (depends on lobe of abscess • CT and MRI used to diagnose

Autonomic Dysreflexia Treatment

• Sit patient up straight, or elevate the head so they are looking straight ahead. • Loosen or take off any tight clothing or accessories. This includes braces, catheter tape, socks or stockings, shoes, and bandages. • Check for wrinkles in the sheets • Check for catheter kinks and ensure the bladder is draining • Use digital stimulation to empty the bowel. • Check skin for red spots that may indicate a pressure sore. • Check blood pressure every 5 minutes to see if it improves if elevated

Subdural Hematoma

• Space between the dura and the brain • Most common cause is trauma • Most often venous in nature • Can have slow bleed over months • Watch for neurological deficits. Patients can change quickly.

Epidural Hematoma

• Space between the skull and the dura • Considered an extreme emergency • Meningeal arteria rupture can cause rapid pressure on the brain • Usually momentarily loss of consciousness followed by lucid interval. • Tx to remove ICP, bur hole (relieve pressure), remove clot, control bleeding • Watch for neurological deficits. Patients can change quickly.

Burns: Special Needs of Nursing Staff

• Specialized burn care makes a critical difference in helping patients not only to survive, but also to cope with and triumph over an intense and complex injury. • Warm, trusting, satisfying relationships frequently develop between burn patients and nursing staff, not only during hospitalization but also during the long-term rehabilitation period. • Difficult to cope with the deformities, odors, unpleasant sight of the wound, reality of the pain that accompanies the burn and its treatment. • Seek help from coworkers, a manager, or the Employee Assistance Program, • Burn nurses need to practice good self-care

Pressure Ulcer Stages

• Stage 1 has unbroken, but pink or ashen (in darker skin) discoloration with perhaps slight itch or tenderness. • Stage 2 has red, swollen skin with a blister or open areas. • Stage 3 has a crater-like ulcer extending deeper into the skin. • Stage 4 extends to deep fat, muscle, or bone and may have a thick black scab (eschar).

Burn Wound Treatment: Multiple Dressing Changes

• Sterile gauze laid over topical antibiotic • Dressings changed from every 12 to 24 hours to once every 14 days depending on the product. • Most burn centers support the concept of moist wound healing and use dressings to cover burned areas, with the exception of facial burns.

Leading causes of bacterial meningitis

• Streptococcus pneumoniae • Neisseria meningitidis • Replaced Hemophilus as flu vaccine emerged (decrease in meningitis)

Brain Injury Nursing Assessment

• Subjective data: was there loss of consciousness? • Level of Consciousness • Glasgow Coma Scale • Eye opening • Best verbal response • Best motor response • Motor strength •Squeeze hands • Pronator drift (raise arms, palms up, eyes closed) • Raise foot off the bed or bend knees • Motor response • Reaction to pain- spontaneous? •Vital Signs •Be aware of cushings triad

Concussion

• Temporary loss of neurologic function • Can involve a period of unconsciousness • Sports injuries • Reversible • S/S: confusion, amnesia, loss of memory, headache, dizziness

Burns Fluid Resuscitation

• The aim of resuscitation is to restore and maintain adequate oxygen delivery to all tissues of the body following the loss of sodium, water and proteins. • MUST if burns involve >15-20% • Delays beyond 2 hours increases mortality. • Prevent burn shock!!!

Burns Prehospital Care

• The burn patient may have sustained other injuries that take priority over the burn wound. • It is important for individuals involved in the prehospital phase of burn care to adequately communicate the circumstances of the injury to the hospital-based health care providers. • Especially important when injury involves entrapment in a closed space, hazardous chemicals, electricity, or trauma (e.g., fall).

What are the Effects of a Spinal Cord Injury?

• The effects of SCI depend on the type of injury, degree of injury and the level of the injury. • Level of injury can be divided into two classifications: complete and incomplete injuries • The lower the injury level, the more function that is retained in the arms • In a cervical cord injury, paralysis of all four extremities occurs (tetraplegia) • Thoracic, lumbar or sacral SCI: result is paraplegia (paralysis of legs)

Metabolic asphyxiation

• The majority of deaths at a fire scene are the result of inhaling certain smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide. • Carbon monoxide (CO) poisoning • CO is produced by incomplete combustion • Inhaled CO displaces oxygen - no room for oxygen (Hypoxia, Carboxyhemoglobinemia, Death)

Emergent Phase Clinical Manifestations: Altered Mental Status

• The patient may be alert and able to provide answers to question until they are intubated. • Patients are often frightened and need calm reassurances and simple explanations. • Unconsciousness or altered mental status in a burn patient is usually results from hypoxia associated with smoke inhalation. • Other possibilities include head trauma, history of substance abuse, or excessive amounts of sedation or pain medication.

Viral Meningitis Treatment

• Treat with antibiotics after obtaining diagnostic sample but before receiving test results • Discontinued when found to be viral • Symptomatic management • Disease is self-limiting • Full recovery expected: rarely any impairments/lasting effects

Emergent Phase Nursing Management: Fluid therapy

• Two large-bore IV lines for >15% TBSA (14-16) • >30% TBSA, central line for fluid /drug administration /blood sampling • Arterial line if frequent ABGs or invasive BP monitoring is needed. • Type of fluid replacement based on size/depth of burn, age, and individual considerations (NS,LR) • Parkland (Baxter) formula for replacement adequacy of fluid resuscitation using Urine output most commonly used parameter.

Burns Replacement Adequacy

• Urine output is most commonly used parameter • Urine osmolarity is the most accurate parameter • Goal: U/O 30-50 mL per hour (higher for electrical burns)

Burns Acute Phase Nursing Management: Artificial Skin

• Used with life-threatening full-thickness/deep partial-thickness wounds where conventional autograft is not available or advisable, dermal and epidermal elements • Can replace all functions of skin • Integra: artificial skin, applied within a few days postburn for greatest success, replaced by the patient's own epidermal autografts. • AlloDerm,: cryopreserved human allograft dermis, from cadavers, is decellularized to make it immunogenic, freeze-dried.

Incomplete SCI: Central cord syndrome

• Usually caused by hyperextension injuries or edema to central cord (whiplash) • Motor deficits that occur in UE; sometimes sensory loss (variable) • Can have bowel and bladder function or deficits

Incomplete SCI: Lateral cord syndrome (Brown-Sequard Syndrome)

• Usually resulted from penetrating injury (knife, bullet, fracture, dislocation of one side) • Acute ruptured disc just on one side • Patients can experience paralysis below the level of injury on the same side of the cord damage; loss of pain and temp on the opposite side of the injured SC (positioning of nerve roots)

Bacterial Meningitis Health Promotion

• Vaccinations for pneumonia and influenza • Meningococcal vaccines: MCV4, MPSV4, Serogroup B • Early, vigorous treatment of respiratory tract and ear infections • Prophylactic antibiotics for anyone exposed to bacterial meningitis

Prehospital Care: Inhalation Injury

• Watch for signs of respiratory distress • Treat quickly and efficiently • 100% humidified oxygen if CO poisoning is suspected • Patients with both body burns and inhalation injury must be transferred to the nearest burn center.

Emergent PhaseNursing Management: PPE/Precautions

• When open burns wounds are exposed: Disposable hats, Masks, Gowns, Gloves • When removing contaminated dressings / washing dirty wound: nonsterile, disposable gloves. • Sterile gloves used when applying ointments and sterile dressings, room must be kept warm (approximately 85°F [29.4°C]). • All PPE is removed/new applied b/4 next patient, to avoid transmitting organisms from pt to pt. • Equipment & environment thoroughly cleaned and disinfected after use, plastic liners on equipment are helpful in ↓ contamination of equipment and facilitates cleaning. • Preventing cross-contamination from one patient to another is a priority

Burns Acute Phase Nursing Management

• Wound care • Excision and grafting • Pain management • Physical and occupational therapy • Nutritional therapy

Partial-thickness wounds

• are pink /cherry red/wet/shiny/ serous exudate, may have intact blisters, are very painful when touched. • Superficial partial-thickness burn: Involves epidermis • Deep partial-thickness burn: Involves dermis

Cultured epithelial autograft (CEA)

• grown from biopsies obtained from the patient's own unburned skin. • sent to a commercial laboratory, biopsied keratinocytes grown in culture medium with epidermal growth factor. In 18 to 25 days expand to 10,000 times, form sheets used as skin grafts. • form a seamless, smooth replacement skin

Symptoms of Increased ICP

• headache • confusion • shallow breathing/irregular resp • nausea/vomiting • increased BP • blurred vision • bradycardia • altered LOC • unilateral pupil dilation • papilledema

Full-thickness wounds

• no blisters, minor, localized/decreased sensation nerve endings have been destroyed. • Dry, dull appearing bc skin has been burned off Involves all skin elements, nerve endings, fat, muscle, bone

Symptoms of a Spinal Cord Injury

• problems walking/unable to walk • loss of control of the bladder or bowels • inability to move the arms or legs • feelings of spreading numbness or tingling in the extremities • unconsciousness • headache • pain, pressure, stiffness in the back or neck area • signs of shock • unnatural positioning of the head

Prehospital Care: Chemical Injuries

• quickly remove solid particles and clothing containing chemical • flush 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.

Medications R/T Head injuries: Mannitol

• reduction of ICP- PROMOTE Osmotic Diuresis. • Expect urine output to

Temporary allograft

• used to test suitability of recipient site to accept a graft, removed days later in OR and autograft applied. • clots between graft and wound keep graft from adhering, occlusive dressings apply just enough pressure to promote adherence of graft to wound bed and to control bleeding.

Bacterial Meningitis Complications

• ↑ ICP (most common): Major cause of altered mental status • Residual neurologic dysfunction: Cranial nerves III, IV, VI, VII, or VIII can become dysfunctional (sequelae varies by cranial nerve) • Optic nerve (CN II) compressed by ↑ ICP: Papilledema with possible blindness • Ocular movements affected with irritation to nerves III, IV, and VI: Ptosis (droopy eyelid), Unequal pupils, Diplopia (double vision) • CN V irritation: Sensory loss and loss of corneal reflex • Inflammation of CN VII: Facial paresis • Irritation of CN VIII: Tinnitus, vertigo, deafness. Hearing loss may be permanent. •Hemiparesis, dysphagia, hemianopsia: If do not resolve suspect cerebral abscess, subdural empyema, subdural effusion, or persistent meningitis •Acute cerebral edema may cause: seizures, CN III palsy, bradycardia. hypertensive coma, death • Noncommunicating hydrocephalus can occur if the exudate causes adhesions that present the CSF from circulating in the ventricles and throughout the brain • CSF reabsorption by arachnoid villi can be obstructed by the exudate - surgical implant of shunt • Waterhouse-Friderichsen syndrome (WFS)

Burns Acute Phase: S/S of Infection

• ↑or ↓ T, ↑ HR & RR, ↓BP & UOP • Mild confusion, chills, malaise, ↓ appetite • WBC count between 10,000 & 20,000/μl • Organisms usually gram-negative bacteria Pseudomonas, Proteus organisms, • Patient at risk for septic shock. • Cultures obtained from all sources, burn wound, blood, urine, sputum, mouth, perineum, IV site. • Treatment immediately begins with antibiotics. • Patient's condition is critical , close monitoring of vital signs and mental status is needed.

Emergent Phase Complications: Urinary system

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

Bacterial Meningitis Nursing Implementation revolve around the nursing diagnoses of

• ↓ Intracranial adaptive capacity • Risk for ineffective cerebral perfusion • ↑ Fever • Acute pain (usually severe head pain)