Burns

Third degree burn (full thickness)

skin is waxy white, dark brown in appearance skin is dry, leathery eschar and there is absence of pain

Compartment syndrome assessment- cap refill

6 P's Paresthesia pain distal to injury which is unrelieved pressure increases in compartment pallor, coolness, loss of color paralysis pulselessness

Arrange the order of airway management in a client with burns.

1. intubation within 1 to 2 hours after injury 2. placed on ventilatory support, providing oxygen concentration based on arterial blood gas values 3. extubation may be indicated when edema resolves, usually 3 to 6 days after initial injury, unless severe inhalation injury is involved 4. escharotomies of the chest wall may be necessary to relieve respiratory distress

Functions of the skin include:

1st line defense against infection Regulates body temperature Able to sense heat, cold, touch, pressure, pain Helps regulate fluids in the body Barrier

Gastrointestinal system complications with burn injuries

>20% TBSA burn= decreased peristalsis Paralytic ileus- obstruction of intestine due to paralysis of intestinal muscles Stress ulcers

Nutritional support

4-6 thousand kcal/day Enteral feedings with feeding tube Central venous catheter if enteral feeding contraindicated

Second degree burn (deep partial thickness)

painful, red to white color

Complications of burns

AFFECTS ALL BODY SYSTEMS Respiratory function compromised CO decreased Tissue perfusion decreased Dysrhythmias, circulatory failure Third spacing Massive infection Fluid and electrolyte imbalance Skin loss Hypothermia

Blood stream becomes concentrated

Blood becomes thick because Na and albumin leave blood stream to go into cells

A client is admitted to the hospital due to electrical burns

Burn odor Leathery skin Cardiac arrest

Usually takes 24-36 hours after injury for

Capillary integrity to be restored

Wound management

Control microbial colonization Prevent wound progression Achieve wound coverage as early as possible Promote function of healing skin

Cardiac interventions

Crystalloid solutions- warmed LR (because worried about hypothermia) through two large bore catheters Hourly urine output- 30-50 ml/hr or 0.5-1 ml/kg/hr HR- should be less than 110 Assess for narrowed pulse pressure- significant hypotension occurs when volume decreases by 30%

On the second day after sustaining extensive severe burns a 6-year-old child exhibits edema and decreased urine output. For which additional adverse response should the nurse assess the child in this early stage of burn injury?

Disorientation may be an initial indication of dehydration or an early sign of hypoxia resulting from respiratory complications Tachycardia

S/S of superficial burn

HA N/V Chills

3 phases of burn healing

Inflammation Proliferation Remodeling

Parkland formula for burns

LR 4 mL X kg body weight X percentage burn TBSA (1/2 volume in first 8 hours and remaining delivered over next 16 hours)

The nurse is caring for a client who has been admitted with partial- and full-thickness burns over 25% of the total body surface area. Lactated Ringer solution and 5% dextrose have been prescribed. What is the purpose of these fluids?

Maintain blood volume Lactated Ringer solution and 5% dextrose in saline are not plasma expanders, as is albumin.

Urinary system complications with burns

Monitor urine output Dead erythrocytes

Treatment of superficial burns

Mild analgesics, application of water -soluble lotions, regular cleaning Extensive superficial burns- IV fluids (elderly)

Full thickness burn

Minimal to absent pain

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for which finding?

Nasal discharge containing carbon particles

Dressing the wound

Open/closed methods Contractures a common problem- tightening of skin ROM Q2 hours Uniform pressure

Which complication may be caused by sepsis in burns?

Paralytic ileus

Water follows

Protein

Escharotomy

Removal of eschar to prevent circumferential constriction

Surgical debridement

Removal of wound to level of viable tissue

S/S of superficial partial thickness burn

Severe pain related to temperature and air exposure

Treatment of full thickness burn

Skin grafting to heal Excision of eschar Topical agents

Inhalation burn

Sooty-colored sputum

A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention?

Starting an intravenous line with a large-bore catheter

Radiation burns

Sunburn, X rays, radiation therapy for cancer patients

Antimicrobials

Systemic infection is leading cause of death in burns

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet?

Tea- is low in K

General management for all types of burns

The administration of tetanus toxoid for prophylaxis

Fluid goes into tissues =

Third spacing

Necrotic tissue management

Wound debridement Hydrotherapy Enzymatic debridement- breaks down necrotic tissue

A client is recovering from full-thickness burns, and the nurse provides counseling on how to best meet nutritional needs. Which client food selections indicate to the nurse that the client understands the teaching?

cheeseburger and a milkshake have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair

First degree burn (superficial)

skin is red in color with minimal edema and pain

Azotemia

the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood

In full thickness burns dead tissue can

Act as a rubber band if it's all the way around the extremity

Carbon monoxide poisoning interventions

Administer 100% O2 high flow immediately via non rebreather

Treatment of deep partial thickness burn

Analgesics Cleaning Gentle AROM and PROM Grafting

Treatment of superficial partial thickness burn

Analgesics Skin substitutes may be used Cleaning

Electrical burn management

Cardiopulmonary resuscitation

Full thickness (3rd degree) burn

Caused by prolonged contact with flames, chemicals, high voltage electric current Involves all layers of skin- may extend into SQ fat, connective tissue, muscle, and bone Pale, waxy, yellow-brown, mottled, charred, non blanching red Wound surface is dry, leathery, firm to touch

Treatment of severe burns

Emergent/resuscitative stage- lasts from onset of burn through successful fluid resuscitation 1. assess airway patency 2. administer O2 as prescribed 3. obtain VS 4. administer IV fluids as ordered 5. elevate extremity above heart unless contraindicated 6. keep warm and make NPO

Urine output is

Most reliable and sensitive non invasive assessment for CO and tissue perfusion

Hyperkalemia

Na is entering cells= K is leaving cells

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?

Smoke inhalation can cause edema of the respiratory lumen, interfering with oxygenation; evaluation of respiratory status is the first

Autografting

Healthy skin from pt to applied burn wound Cultured epithelial autografting 3-4 weeks process of skin growth

A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation?

1. A jaw-thrust maneuver helps to establish an airway and breathing 2. bag-valve-mask (BVM) ventilation with 100 percent oxygen source ensures ventilatory assistance. 3. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. 4. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. 5. The clothes of the client are removed with scissors to prevent fabric melting into the skin.

Proliferation phase

2-3 days post burn Granulated tissue begins to form Epithelial cells begin to cover wound as each cell stretches across wound surface Lasts until complete re epithelialization occurs

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction?

A brassy cough is indicative of possible pulmonary damage caused by an inhalation burn Singed nasal hair indicates possible pulmonary damage Dark mucous membranes are a sign of potential respiratory insufficiency that results from inhalation burns

Diagnostic tests for burns

Pulse ox Carboxyhemoglobin measurement- for carbon monoxide poisoning ABGs 12 lead ECG Serial CXR studies UA CBC- decreased RBC, increased WBC Serum electrolytes Renal function test- decreased GFR, increased BUN, creatinine, urine specific gravity, uric acid Total protein Albumin C reactive protein- shows inflammation Blood glucose- increased

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns?

Administer the prescribed intravenous fluid with the added vitamin C. Vit C is ESSENTIAL for wound healing

Pharm therapy for burns

Anxiety and pain control- IV narcotics, anti anxiety agents, alternative therapies Antimicrobials- diagnose infection through wound biopsy, broad spectrum/topical/prophylactic abx Antacids- gastric aspirant through NG tube

Inflammation phase

Begins immediately Platelets aggregate at damaged tissue Thrombus forms Local vasoconstriction causes hemostasis Neutrophils, monocytes, macrophages Secrete growth factors to stimulate deposit of a wound matrix

S/S of burn shock

Decrease in fluid volume within vascular space to interstitial compartment due to loss of cell wall integrity CO decreases- hypotension, urine output decreases, HR increases Body compensates with vasoconstriction, but only for so long Abnormal platelet aggregation and WBC accumulation result in ischemia in deep tissue Edematous body surfaces impair peripheral circulation- results in necrosis of underlying tissue Hyperkalemia- high risk for dysrhythmia due to potassium leaving intracellular compartment

S/S of deep partial thickness burn

Capillary refill decreased Intact hair follicles Decreased sensation at site

Electrical burn

Cardiac arrest

Hypovolemic shock s/s

Decreased CO Hypotension Tachycardia Tachypnea Vasoconstriction

Risk factors for burns

Children under 4- don't understand dangers, lack ability to react appropriately Older adults- slower reaction time, impaired mobility, sensory impairment Pre existing medical conditions- COPD, HF

A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route?

Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury The medication begins to work in minutes; doses can be controlled Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue Impaired peripheral circulation is bypassed

Tissue damage is determined by

Depth- how many layers of tissue is affected Extent of burn- % of BSA involved

Chemical burn

Direct contact between skin and acid/alkaline agents, organic compounds Severity is based on chemical agent, mechanism of action, duration, contact, and amount of BSA exposed

Thermal burn

Direct exposure to dry (flames) or moist heat (steam, hot liquids) Most common Usually affect children and adults over 65 Causes cellular destruction- may result in charring of vascular, bony, muscle, and nervous tissue

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportional

A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication?

Disorientation with twitching Excess extracellular fluid moves into cells (water intoxication) Intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include anorexia, nausea, vomiting, sleepiness, and convulsions

Respiratory interventions for burns

Elevate HOB 30 degrees Humidify room air or O2 Intubation if necessary Suction frequently Meds to dilate constricted bronchial passages ART line to monitor ABGs

Rules of nine for burns

Head and Neck= 9% Each upper ext= 9%- 18% Each lower ext= 18%- 36% Anterior trunk= 18% Posterior trunk= 18% Genitalia/perineum= 1%

S/S carbon monoxide poisoning

Headache Cherry red colored skin Nausea Dizziness Coma Death

The beginning of the acute phase of burn recovery (36 to 48 hours after the injury) is evident by hemodynamic instability

Expect to see unstable vital signs

Superficial partial thickness burn

Extends from skin's surface into papillary layer of dermis Ex- contact of hot surface, dilute chemical agents Bright red, moist, glistening, blisters Usually heals within 21 days

1st 24 hours

FLUIDS is most important in stabilizing pt especially with fluid shift the pt will have

Carbon monoxide safety alert

False normal pulse ox reading because Pulse ox can't distinguish O2 from hemoglobin Carbon monoxide binds to hemoglobin Pt will stat normal, but actually have hypoxia

Hyperkalemia clinical manifestations

Fatigue, paresthesias, and cardiac dysrhythmias

A client with burns caused by flames is hospitalized. Which specific emergency burn management would be appropriate for this client?

First remove all smoldering clothing and metal objects

A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check?

Hct An increased Hct level indicates hemoconcentration secondary to fluid loss.

Radiation burns management

Help to bathe or shower

Inhalation burn

Hoarseness

S/S of airway obstruction due to edema

Hoarseness Labored breathing Stridor

Biological and biosynthetic dressings

Homograft- allograft- biological Heterograft- xenograft- biosynthetic

Cardiac complications with burns

Hypovolemic shock/burn shock- within minutes after major burn Dysrhythmias- pts with electrical burns, hyperkalemia Peripheral vascular compromise- circumferential burns encircles an extremity, compartment syndrome

Burns involving 40% or more of TBSA

Increase in microvascular permeability at burn wound site Generalized impairment of cell wall function resulting in intracellular edema Increase in osmotic pressure of burned tissue leading to extensive fluid accumulation

Integumentary system complications with burn injuries

Infection secondary to loss of integrity Difficulty maintaining body temperature Eschar formation during acute stage

Respiratory complications with burns

Inhaltion injury- often lethal ARDS Pulmonary edema Atelectasis Airway edema peaks 24-48 hours- assess for singed facial, scalp, nasal hair Smoke poisoning Carbon monoxide is colorless, odorless, tasteless and has 200 times greater binding to hemoglobin than oxygen

Partial thickness (second degree) burn

Involves both epidermis and PART of the dermis Two categories- superficial partial and deep partial

Superficial (1st degree) burn

Involves epidermis only Burned skin remains intact Heals in 3-6 days Painful, red, slight edema, no blistering- sunburn, radiation

Deep partial thickness burn

Involves the dermis and extends to reticular layer of dermis Ex- hot liquids/solids, flash flame, direct flame, intense radiant exposure, chemical agents Pale, waxy, moist or dry blisters Scarring, contractures are possible Usually require more than 21 days to heal

Burn shock

Massive fluid shifts of plasma, electrolytes, and proteins into the burn wound causing edema Usually occurs within first 24 hours of injury Inability to maintain fluid in cells within vascular space

Remodeling phase

May lasts for years Collagen fibers reorganize into more compact areas Scars contract and fade in color

S/S of full thickness burn

NO capillary refill Hair follicles NOT intact- pt will not know pulling hair out No sensation of pain or light touch at site due to destroyed pain/touch receptors

Hyponatremia

Na is leaving blood stream and going into the cells

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication?

Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change

A preschooler with partial-thickness burns on 21% of the total body surface area progresses from the emergency phase to the acute phase of burn care. What is the most important nursing intervention at this time?

Pain management plan

Chemical burn

Paralysis is most likely due to chemical burns caused by chemical fumes

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours?

Pulmonary distress The immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs

Pulse Pressure (PP)

SBP-DBP The force the heart generates each time it contacts <40 is low Early indicator to see if pt is having a problem

Electrical burn

Severity depends on type, duration, voltage Electricity follows path of least resistance- usually muscles, bones, blood vessels, and nerves Depth of injury may not be evident until weeks after initial burn event May cause seizures, cardiopulmonary arrest

Initial wound care

Stop burning- tepid (Luke warm) water Remove all clothing and jewelry Cover with clean dry sheets to avoid hypothermia Elevate extremities to reduce swelling NO ointments unless directed by burn unit NO ice or other home remedies

Second degree burn (superficial partial thickness)

painful, reddened, and have blisters pink to cherry red skin with blisters Spontaneous epithelial regeneration occurs within several weeks

A 2½-year-old child is admitted to the hospital with deep partial-thickness burns involving the face and chest. The nurse bases a plan of care on concerns related to the child's injury. Place the following concerns in their order of importance.

impaired gas exchange disturbed fluid balance presence of pain potential for infection compromised body image