BURN INJURIES
Severity of burns are associated with...
age; burn depth; extent of body surface area injured; presence of of inhalation injury; presence of other injuries; location of injury (ie face, the perineum, hands, or feet
An immediate primary survey (FIRST 24-48 HOURS) of the patient is carried out to assess the ABCDEs: What are the meanings?
airway (A) with consideration given to protecting the cervical spine, gas exchange or breathing (B), circulatory and cardiac status (C), disability (D) including neurologic deficit, expose and examine (E) while maintaining a warm environment
In the burn injury, some red blood cells may be destroyed and others damaged, resulting in ...............-->↓ oxygenation, may also cause abnormalities in coagulation, including a decrease in.......... and prolonged clotting and prothrombin times.
anemia platelets (thrombocytopenia)
(Burns)As a compensatory response to intravascular fluid loss, the sympathetic nervous system (SNS) releases........ resulting in an........... in peripheral resistance (vasoconstriction) and an ...... in pulse rate that further .......... C.O. (tissue perfusion).
catecholamines ↑ increase ↑increase ↓decreases
Burn pathophysiology: zone of coagulation is in the.............. area. Characteristics of coagulation is necrosis of the............
central cells
A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? a) Moisten with saline. b) Keep Acticoat saturated. c) Moisten with sterile water only. d) Use topical antimicrobials with Acticoat burn dressing.
**Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.
A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: a) apply maximum bandages to allow for absorption of drainage. b) wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. c) wrap elastic bandages distally to proximally on dependent areas. d) remove bandages with clean gloves.
**wrap elastic bandages distally to proximally on dependent areas. Explanation: Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn't use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.
Lund and Browder method
*more precise method --> the percentage of surface area of of various anatomic parts, esp head and legs as it r/t age of the patient --> done initially then revised first 72 hours b/c demarcation of the wound and its depth present themselves more clearly
Rules of Nines
*most commonly used --> dividing anatomic regions, each representing ~9% of the TBSA
Pulmonary Alterations: Upper airway injury (above the glottis) or inhalation (below the glottis). Indicators of airway injury: --> Burned that occurred................... --> burns to face or neck --> singed ................ --> ..............................., dry cough, stridor --> ..................... or bloody sputum --> labored breathing or tachypnea -> ..................... or blistering of the oral or pharyngeal mucosa
- in an enclosed space -nasal hair -hoarseness -sooty -erythema
four types of débridement— natural,.............. mechanical,............................ chemical................................... surgical..........................................
- the devitalized tissue separates from the underlying viable tissue spontaneously. Bacteria present at the interface of the burned tissue and the viable tissue gradually liquefy the fibrils of collagen that hold the eschar in place. -use of surgical tools to separate and remove the eschar. -Topical enzymatic agents are available to promote débridement of burn wounds. Because such agents usually do not have antimicrobial properties, they may be used together with topical antibacterial therapy to protect the patient from bacterial invasion. -Early surgical excision to remove devitalized tissue along with early burn wound closure is now recognized as one of the most important factors contributing to survival in a patient with a major burn injury.
Large-bore IV catheters.............................. and an indwelling urinary catheter are inserted, if not already in place, and the nurse's assessment includes..................... assessment of intake and urine output.
-(14 to 18 gauge) -hourly
During treatment, the patient is continuously assessed for signs of hypothermia. The temperature of the water is maintained at ........................., and the temperature of the room should be maintained between ............................ to prevent hypothermia.
-37.8°C (100°F) -26.6°C and 29.4°C (80°F and 85°F)
The infusion is regulated so that one half of the calculated volume is administered in the first.........post burn injury. The second half of the calculated volume is administered over the next 16 hours.
-8 hours
.................................................... are the most important energy source for these patients to ensure proper wound healing. Fat, although a required nutrient, should be provided in more limited quantities. In addition, recommendations from recent literature advocate requirements of 1.5 to 2 g/kg/day
-Carbohydrates -protein -
.......................................are skin obtained from recently deceased or living humans other than the patient.................consist of skin taken from animals (usually pigs). Therefore, the body's immune response will eventually reject them as a foreign substance.
-Homografts (or allografts) -xenografts (or heterografts)
.....................................Antimicrobial agent for gram-positive and gram-negative organisms. Is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis (D/C if it does). Rapidly diffuses through eschar and avascular tissue (e.g., cartilage) . Application may cause considerable pain initially. ***Used for ............................burns.
-Mafenide acetate 5%-10% (Sulfamylon) hydrophilic-based solution or cream. -electrical
....................., an anabolic steroid, is commonly administered to patients with burns because it improves protein synthesis and metabolism. Administration of ............................. (a beta-blocker) not only decreases heart rate but also blocks harmful catecholamine effects. And lastly, .................... is described as an essential adjunct in the plan of care for patients with burns, because it attenuates (reduces effect of) the hypermetabolic response.
-Oxandrolone -propranolol (Inderal) -exercise
Carbon monoxide poisoning is a factor in most fatalities at the scene of a fire. Carbon monoxide combines with hemoglobin to form......................... The affinity of hemoglobin for carbon monoxide is................greater than that for oxygen, and if significant quantities of carbon monoxide are present, then tissue hypoxia will occur
-carboxyhemoglobin -200 times
As a burn wound heals, scar contractures, and hypertrophic tissue (excessive scar formation that is above the level of skin) can form. Lubrication, massage, and ......................... can help minimize this complication.
-pressure garments (typically worn 23 hours a day for a year)
Occlusive dressings and ............................ may be used to immobilize the graft. When turning or positioning the client the nurse should be careful not to apply pressure to the graft. The initial dressing change is usually performed ........to........... days after surgery.
-splints -2 to 5
Hypermetabolism occurs immediately after a burn injury. The nurse must support nutrition b/c it is important to prevent infection and promote...........................................Placing a feeding tube past the pyloric sphincter (.................. feedings) decreases the risk for aspiration and SUPPORTS THE IMMUNE SYSTEM.
-wound healing -enternal
Amount of fluid given depends on how much IV fluid per hour is needed to maintain the hourly urine output at.....
0.5 mL of urine/kg/hr
The fluid resuscitation formula for adults within 24 hours post thermal or chemical burns is as follows:
2 mL LR × Patient's weight in kilograms ×%TBSA 2nd-, 3rd-, and 4th-degree burns (2mL/kg/%TBSA)
Deep partial thickness (2nd degree) healing time....
2 to 3 weeks (depends on depth of dermal injury)
The greatest volume of fluid leak occurs in the first hours....... after the burn, peaking by ............
24 to 36 6 to 8 hours
Fluid loss may be >..................liters over ..................... hours
3-5 24
The fluid resuscitation formula for adults within 24 hours With electrical burns:
4 mL LR × Patient's weight in kilograms ×%TBSA 2nd-, 3rd-, and 4th-degree burns (4mL/kg/%TBSA)
Total of burns are caused by ____% flame related; ___%scald injuries; ___% direct source;
44; 33; 9
The acute/intermediate phase of burn care follows the emergent/resuscitative phase and begins................hours after the burn injury
48 to 72
Burn Centers: ppl acquired burns______% at home; ______% industry related____%; recreationally related; ____%other
68; 10; 5; 17
in electrical injuries a urine output of.............. per hour is the goal
75 to 100 mL
During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? a) Applying continuous-compression wraps b) Maintaining wound care irrigation c) Wearing clothing to protect the burn from the sun d) Removing eschar from the skin
Applying continuous-compression wraps Explanation: Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming. Removing eschar from the skin, wearing clothing to protect the burn from the sun, and maintaining wound care irrigation are appropriate for the client with a burn wound, but these interventions don't necessarily help minimize scarring.
................................. remains the preferred autologous method for definitive burn wound closure after excision. They are the ideal means of covering burn wounds because the grafts are the patient's own skin and therefore are not rejected by the patient's immune system.
Autografting
One widely used synthetic dressing is ............................., a dual-layer dressing of nylon and silicone. The material is porous, semitransparent, and sterile. It has an indefinite shelf life and is less costly than homograft or xenograft such as pigskin. As it gradually separates, it is trimmed away, leaving a healed wound. Protects the wound from fluid loss and bacterial invasion.
Biobrane
Nursing interventions for .............................. 1. Assess gastric aspirate and stools for blood. 1. Blood indicates possible gastric or duodenal ulcer bleeding • Gastric aspirate and stools do not contain blood. 2. Administer histamine-2 blockers and/or antacids as prescribed. Such medications reduce gastric acidity and risk of ulceration.
Curling's Ulcer
Cardinal sign of inhalation injury is....................
Expectoration of carbon particles in the sputum
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? a) Anemia b) Hyperthyroidism c) Gastric ulcers d) Cardiac arrest
Gastric ulcers Explanation: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.
Rule of Nines divides anatomic regions, each representing 9%.............and.............18%........,...........,and.............1%.................
Head and arms each; anterior trunk, posterior trunk, and legs each perineum
A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client? a) Hemoconcentration b) Lack of erythropoietin factor c) Metabolic acidosis d) Hemodilution
Hemodilution Explanation: Reduced HCT is caused by hemodilution, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbunimemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced HCT level in this situation. Erythropoietin factor is reduce if kidney failure occurs; however, lack of erythropoietin factor doesn't impact hematocrit level.
(-) Nitkolsky's sign
If burn is rubbed, the burned tissue does not separate from the underlying dermis
.................................is the crystalloid of choice because its composition and osmolality most closely resembles plasma and because the use of normal saline is associated with hyperchloremic acidosis
LR
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation? a) Hypernatremia b) Elevation of blood glucose levels c) Myoglobin in the urine d) Increase in antidiuretic hormone (ADH)
Myoglobin in the urine Explanation: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.
.................................. is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%
Posttraumatic stress disorder (PTSD). Which manifests as : flashbacks or nightmares
Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? a) Reduction in blood volume b) Increased urinary output c) Potassium deficit d) Sodium excess
Reduction in blood volume Explanation: A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.
In what burn phase is the ultimate goal is to return patients to the highest level of function possible within the context of their injuries.
Rehabilitation Phase
Most commonly used method to determine TBSA
Rule of Nines
.................................... is a leading cause of morbidity and mortality in patients with burn injuries.
Sepsis
......................................effective against most strains of Staphylococcus and Pseudomonas and many gram-negative organism. Monitor serum sodium (Na+) and potassium (K+) levels b/c it pulls them out of the cells. Does not penetrate eschar. Protect bed linens and clothing from contact, which stains everything it touches.
Silver nitrate 0.5% aqueous solution
The gold standard for protecting burns is.............................. It has minimal penetration of eschar. Anticipate formation of pseudo-eschar (proteinaceous gel), which can be removed.
Silver sulfadiazine 1% (Silvadene) watersoluble cream
The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? a) Mafenide (Sulfamylon) b) Cerium nitrate solution c) Sulfadiazine, silver (Silvadene) d) Gentamicin sulfate
Sulfadiazine, silver (Silvadene) Explanation: With use of silver sulfadiazine (Silvadene), the nurse should watch for leukopenia 2 to 3 days after initiation of therapy. (Leukopenia usually resolves within 2 to 3 days.)
Which of the following is a potential cause of a superficial partial-thickness burn? a) Scald b) Electrical current c) Flash flame d) Sunburn
Sunburn Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.
Acute/intermediate burn Phase priorities...
Wound care and closure • Prevention or treatment of complications, including infection • Nutritional support
In the acute/intermediate phase capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and .................... begins.
diuresis
Proper management of burn wounds is required to prevent wound deterioration and/or infection. The goal of wound care is ............................... of nonviable tissue, removal of previously applied topical agents, and application of new topical agents
débridement
Colloids decrease the amount of fluid needed helping to prevent massive............................formation
edema
Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities ................................
elevated
Deep partial thickness (2nd degree) burns cover the...
entire epidermis and varying portions of the dermis
Full thickness (3rd degree) is the total destruction of the...
epidermis and dermis and in some cases, underlying tissue
1st degree burns manifest as
erythermatous, but epidermis intact, min or no edema
Fluid and Electrolyte Alterations. Edema forms rapidly after a burn injury. Severity is dependent on severity of the injury. As edema increases, pressure on small blood vessels in the distal extremities causes an obstruction of blood flow and consequent ischemia, causing compartment syndrome. Treatments may include decompression via....................
escharotomy
Phases of Burn Care: Emergent/resuscitative phase. From onset of injury to completion of ..................• Primary survey: A,B,C,D,E • Prevention of shock • Prevention of respiratory distress • Detection and treatment of concomitant injuries
fluid resuscitation
Formulas only serve as................. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response (ie HR, BP, urine output). This is the primary determinant of actual fluid therapy.
guidelines
Effective fluid replacement can be evaluated by......................, ......................................., and ..............................................
heart rate, blood pressure, and urine output
what baselines are obtained initially after a burn?
height, weight, arterial blood gases, hematocrit, electrolyte values, blood alcohol level, drug panel, urinalysis, and chest x-ray
During the acute phase aerosolized.......................is commonly prescribed to inhibit airway fibrin clot formation, minimize barotrauma, and reduce pulmonary edema
heparin
Immediately after burn injury,............... may result from massive cell destruction. ...............may be present as a result of plasma loss. It may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.
hyperkalemia Hyponatremia
Indications of possible pulmonary changes after a burn injury.........
incident occurred in an enclosed space; facial and/or neck burns; singed nasal hair; high-pitched voice changes, stridor; soot-tinged sputum; labored respirations; erythema and blistering of the oral or pharyngeal mucosa
The major goals for client in rehab phase
increased mobility and participation in activities of daily living; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; increased understanding and knowledge of the injury, treatment, and planned follow-up care; and absence of complications.
Burn pathophysiology: zone of stasis is the area of.......... cells that may remain viable, but with persistent............. blood flow. Will undergo necrosis within 24 to 48 hrs.
injured decreased
In medical managment of burns fluid resuscitaion is needed. ...............is the crystalloid of choice because its composition and osmolality most closely resembles plasma and because the use of normal saline is associated with hyperchloremic acidosis
lactated Ringers (LR)
Clients with Deep partial thickness (2nd degree) are given.... by ....... to control pain
morphine sulfate or other opiates by IV
Full thickness (3rd degree) can damage........leading to the development of myoglobinuria (red pigment in urine) in which case urine output becomes burgundy. The client might require hemodialysis to prevent.........and acute renal failure.
muscles....tubular necrosis
Burgundy-colored urine suggests the presence of hemochromogens and ............................ resulting from muscle damage. This is associated with deep burns caused by electrical injury or prolonged contact with flames.
myoglobin
Immunologic Alterations: ↓r/t loss of skin integrity, release of abnormal inflammatory factors, impaired function of lymphocytes and .........................
neutrophils
1st degree burns heals within....
one week...although the skin peels, there is no scarring
(Burns) Cardiovascular: Fluid loss--> hypovolemia--> ↓C.O. perfusion and oxygenation--> ↓BP=
onset of burn hypovolemic shock (loss of capillary integrity and subsequent shift of fluid, Na+, and protein from intravascular space into interstitial space
Burn pathophysiology: zone of hyperemia is the........area and sustains the least damage. The client may fully recover over time.
outermost
Full thickness (3rd degree) wounds color ranges from...
pale white to red, brown, or charred; appears leathery
Gastrointestinal Alterations: Three of the most common GI alterations in burn-injured patients are.......................... (absence of intestinal peristalsis), Curling's ulcer (gastric or duodenal erosion-Gastric bleeding secondary to massive physiologic stress may be signaled by occult blood in the stool, regurgitation of "coffee ground" material from the stomach, or bloody vomitus) and overgrowth of GI bacteria.
paralytic ileus
Full thickness (3rd degree) in electrical burns, can manifest as whitish areas at the....... and ..........Can result is changes in heart rhythm or complete cardiac standstill.
points of entry AND exit
Lund and Brower Method is more .........The percentage of surface area of various anatomic parts, esp head and legs (change with growth) as it r/t ........ of the client. It is done initially then revised........hrs b/c demarcation of the wound and its depth present themselves more clearly. Used to measure.......in children.
precise age 72 hours TBSA
Full thickness (3rd degree) result from...
prolonged exposure to hot liquids or open flame, electrical current, or exposure to chemical agents
Renal: Destruction of.............. at the injury site results in free hemoglobin in the urine; fluid loss; ↓ C.O. all ↓renal perfusion.
red blood cells
Thermoregulatory Alterations: Loss of skin also results in an inability to....................................
regulate body temperature
Deep partial thickness (2nd degree) injury is common in...
scalds, flash flames, or contact
Palmer Method is used for........burns
scattered
Palmer Method
scattered burns
1st degree burns caused by...
sunburn, superficial scald, or low-intensity flash
1st degree burns what part of the skin
superficial injuries that involve only the outermost layer of skin
Deep partial thickness (2nd degree) area involved appears.....AND feels....
weeping and edema with blister formation AND painful; hair follicles and skin appendages remain intact
In a Full thickness (3rd degree) injury there is a destruction of nerve endings that leave the affected area relatively...
with NO PAIN; no hair follicles and no sweat glands
A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply. a) "This medication will stain my skin permanently." b) "This medication will be applied directly to the wound." c) "This medication will help my burn heal." d) "This medication is an antibacterial."
• "This medication will be applied directly to the wound." • "This medication will help my burn heal." • "This medication is an antibacterial." Explanation: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient's skin, but it will help heal the patient's burned areas.
The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply. a) Heart rate b) Urine output c) Blood pressure d) Oxygen saturation
• Blood pressure • Urine output • Heart rate Correct Explanation: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits
American Burn Association Criteria for Referral to a Burn Center
• Partial-thickness burns covering 10% of total body surface area or greater • Burns involving the face, hands, feet, genitalia, perineum, or major joints • Third-degree burns • Electrical burns, including lightning injury • Chemical burns • Inhalation injury • Burn injury in patients with preexisting medical disorders • Any patients with burns and concomitant trauma • Children with burn injuries in facilities that do not specialize in pediatric care • Patients who will require special social, emotional, or longterm Rehabilitation
Rehabilitation burn phase priorities....
• Prevention and treatment of scars and contractures • Physical, occupational, and vocational rehabilitation • Functional and cosmetic reconstruction • Psychosocial counseling