burns

If burns over 15% TBSA what type of IV do you need?

(2 large bore catheters)

What is the most important goal in this phase?

Airway Assess patency & ventilation Look for singed nasal hairs, soot ****Face & Neck Burns = Intubation within 1-2 hours Inhalation injury/ Carbon Monoxide = 100% humidified O2 PRN ABGs CXR Prepare for Fiberoptic Bronch

ABCs

Airway Breathing Circulation Disability Exposure

A client has just arrived to the Emergency Department and has sustained burns on the front and back of the right arm and leg. Using the rule of 9s, what is the body surface area percentage? A) 27% B) 18% C) 36% D) 9%

Answer: A Rationale: A nurse can estimate the % of the body area burned using the rule of 9's. Each arm (front and back) is 9% each leg is 9% front and 9% back.

The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

Answer: C Rationale: To prevent the complication of contractures the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures.

When assessing a pt with a partial thickness burn, the nurse would expect to find (select all that apply) a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

a, d, e

Skin grafting can be

autografting (skin from another part of the body).

When would you want the urine more than that?

electrical burn

parkland formula for burns

% BSA x weight (kg) x 4mL(LR) give 1/2 fluids in first 8 hours. remaining 1/2 in last 16 hours.

If burns over 30% TBSA what type of IV do you need?

(central line)

immediate intervention for inhalation injury The pt may need intubation. Assess pt for inhalation injuries.

***LOOK UP THEIR NOSE, look in the back of their throat and mouth (look for swelling), if swelling, immediately secure their airway.

Knowing that the adult client weighs 174.74 lbs and has a TBSA that is 36% use the Parkland Formula calculate the fluid to be infused over the first 24 hours after the burn injury: ____________________ mL

11,376 mL in 24 hours 4mL x 36% x 79 kg= 11,376

Death from Carbon Monoxide Poisoning assessment

61-80% will lead to death. O2 shows you the oxygen saturation (will detect the saturation in a hemoglobin molecule), want O2 sat >95, COPD varies. Tells you that the hemoglobin molecule is saturated, then their O2 sat may be normal.**

Rule of Nines (adult)

9% per entire arm 9% for entire head 18% each whole leg 18% anterior trunk 18% posterior trunk 1% for genitalia

Once fluid replacement begins

= Resuscitative Phase

An adult patient is brought into the ED after suffering from third degree burns in an explosion. The patient has burns on approximately 42 percent of his body. The nurse weighs the patient and notes that he weighs 78 kg. A: Calculate the rate of IV fluid this patient must receive in the first 24 hours using the Parkland formula B: What is the mL/hr to be infused in the first 8 hours after arrival.

A: 13,104 mL in the first 24 hours B: 819 mL/hr for the first 8 hours

Which client is most at risk for compartment syndrome due to a burn? A. A 25 yr old with circumferential burn of the anterior and posterior left arm. B. A 7 yr old with a burn of the left and right ear. C. A 54 yr old with an electrical burn on the neck. D. A 16 yr old with a chemical burn to the right foot.

A: Circumferential burns of the extremities are more likely to cause compartment syndrome, because they produce a tourniquet-like effect, which can lead to vascular problems.

Inhalation Injuries Associated with Burns what is always a Priority concern after Inhalation Injury

AIRWAY

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid).

ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

ANS: D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.

after the first 12-24hrs what fluids do you provide?

Albumin * Recommended after first 12-24 hours Dextrose/Electrolyte Replacements * After 12-24 hours

What causes deeper burns usually?

Alkalins cause deeper burns.

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)

Ans: A Feedback: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from the viable tissue B) Removal of eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

Ans: B Feedback: Mechanical dÈbridementcan be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical dÈbridement can also be accomplished through the use of topical enzymatic dÈbridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural dÈbridement. Shaving the burned skin layers and early wound closure are examples of surgical dÈbridement.

A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Select all that apply.) A) Age B) Depth of the burn C) Presence of inhalation injury D) Family support E) Psychological state of the patient

Answer: A, B, C Rationale: The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? a. 18% b. 22.5% c. 27% d. 36%

Answer: B Rationale: Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

Answer: D Rationale: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Full partial thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.

A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have? A) 10% B) 25% C) 9% D) 18%

Answer: D Rationale: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

assessment of FULL thickness burns

Areas can be black (eschar), no sensation at all, no pain (nerve endings dead), this healing takes months and skin grafts are def required.

Thermal Burn Specific Interventions

Assess for inhalation injuries Stabilize C-spine Begin fluid replacement Insert Foley Catheter

Calculate the total fluid to be infused in the first 8 hours after arrival for an adult burn victim weighing 81 kg with a TBSA of 19%: A: 2,798 mL B: 3,078 mL C: 12,312 mL D: 6,156 mL

B: 3078 mL 4mL x 19% x 81 kg= 3078 mL

second degree burn

Blisters Mottled Moderate to severe pain

Stabilize the c-spine! If trauma victims come in, do not move their neck instead

C-collar will be on, if not, get one on. If you need to stabilize their c-spine and secure an airway, then do a jaw thrust (TMJ pressure).

The biggest issue with Facial/head burns

Can cause resp problems. Any type of facial/head burns, do a major resp assessment on them.

Without intervention, what can frost bite lead to?

Can progress to Gangrene

Severe Carbon Monoxide Poisoning assessment

Coma Seizures Severe: They will slip into a coma, have, seizures. 41-60%

Muscular System effect of burns

Contractures, problems related to mobility, and scar formation.

What treatments work for this?

Cool compresses but maintain warmth OTC pain meds Antihistamines Aloe vera lotion Hydration No heating pads, or ice packs Avoid deodorants Moisturize dry skin with nonirritating lotion

Skin white, hard, insensitive to touch

Deep Frostbite

DEEP partial thickness burn assessment

Deep cherry red, usually no blister because the top layer of tissue is dead. The wound surface will be red and dry with white places that appear, moderate edema, may/may not blanche

lightning can cause v fib. what would you do?

Defib!!

what kind of fluids can you use for a burn victim?

Determine extent of burns using standardized chart Lactated Ringer's * First 24 hours

How do you treat a SUPERFICIAL partial thickness burn?

Do not put cold on this one. Takes 10-21 days to heal, and there is usually no scarring (may have minimal changes but no scarring).

, alkalins-

Draino, oven, cleaners, bleach,

Third Degree +

Dry, leathery, eschar Waxy white, dark or charred Decreased sensation directly to burn but surrounding tissue very painful

What must be removed for healing to occur?

ESCHAR must be removed for healing to occur.

What is an escharotomy?

Escharotomy removes pressure in the chest cavity. Escharotomy can be done at the bedside with anesthesia because nerve endings are gone. Removing eschar can relieve the pressure****. It does not prevent edema formation.

What are the important interventions at the hospital?

Evaluate the degree of injury Ensure patent airway and administer 100% O2- Assess need for intubation Establish IV Access Monitor VS Insert Foley NPO Insert NG tube Tetanus Administer I.V. analgesia Prepare for Escharotomy or Fasciotomy if needed

Chemical burns are from

Exposure to Acids & Alkalis & organic compounds

what assessment would you find with a smoke inhalation injury?

Facial Burns Erythema Swelling of oropharynx and nasopharynx ***Singed nasal hairs Flaring nostrils Stridor, wheezing and dyspnea Hoarse voice Sooty sputum & cough Tachycardia Agitation & anxiety

How to neutralize?

Figure out what the substance one and then call poison control.

what commonly causes deep partial thickness burns?

Flame, scalds, or hot grease commonly produce deep second-degree burns.

CV system effects of a burn

Fluid volume deficit!! Hypovolemic shock. MAP drops, organs become poorly perfused, can cause ECG changes and arrhytmias.

How do you prevent renal damage?

Fluids! Lots of it. Insert Foley Catheter - Maintain urine output 100ml/hr

Goal of the rehabilitative stage?

Gain independence and achieve maximal function

organic compounds

Gasoline, creosote

What types of medications will you give?

Give IV, IM will not be absorbed. Sedatives: Fentanyl, etc. Pt will need antidepressants on long term, pt will be put on anticoags because of bed rest.

What do you do for a superficial burn? How long does it take to heal? scars?

Give cool compresses, will make it better. Pain only lasts 48 hrs, heals in 3-5 days, and no scarring associated with this burn.

Mild Carbon Monoxide Poisoning assessment

Headache Flushing Decreased cerebral functioning Slight breathlessness Mild listed above. 11-20%

Moderate Carbon Monoxide Poisoning assessment

Headache N/V Drowsiness Confusion Pale to reddish-purple skin Moderate: neuro signs will get worse. May get nauseated, vomit. Will become drowst and confused, skin can look purple. 21-40% of carbon monoxide in their blood.

What happens to the cells in a burn?

Histamine is released, causes capillaries to increase their permeability. This leads to edema. Increases Capillary permeability Edema Decreased Intravascular Volume

complications with full thickness burns

If they had bad burns like this and it burns their tendons, ligaments, then the pt will lose feeling and movements. They are at risk for decreased feeling at the site and contractures because they can't move it properly. Need lots of PT.

Renal System effect of burns

Indirect effect of decreased CO, kidneys will start to die, AKI. Myoglobin can cause renal failure, red/brown urine.

Acids can be

Industrial products Acids are common in household cleaners (bathroom cleaners, draino)

interventions in the emergent stage(paramedics)

Initial Assessment/Treatment of Life-threatening injuries Remove from the source of the burn Prevent further injury Stabilize the patient's cervical spine

Scarring and disfigurement can be a huge part of this phase. What helps with this?

JOBST garment can apply pressure and help keep the scar flat and won't let it get hypertrophic. Need it for 23 hrs a day.

What are assessment findings will you find for SUPERFICIAL partial thickness burns?

Large blisters can cover an area, edema is present, the base looks modeled (red and white combined), can have a wet, shiny, weepy surface. This type of burn is painful and VERY sensitive to cold air

Inhalation Injuries Associated with Chemical Burns

Lower Airway Injury Pulmonary Edema ARDS

What will the autografting look like? assessments?

Mesh will be oozy, red, and eventually will start granulating and regenerating. Part will be immobilized for 3-5 days. ALWAYS monitor for infection (smell, drainage, increased temp).

Neuroendocrine: System effect of burns

Metabolic rate will go way up, need lots of calories. Cortisol levels are very high (stress response), can have insulin resistance and hyperglycemia.

What happens during this type of burn that can cause urine output to drop?

Myoglobinuria: muscles get damaged, they will release myoglobin, can clog up the kidneys and cause renal damage.

What do you need to know about nutrition needs of a burn victim?

Nutrition: high caloric needs. BMR is 40-100x higher than a person without this injury. Need high protein, high fat, and high carbs. Feed them ASAP, may not be able to eat, so they will get TPN. Let them eat as soon as they can, let them eat high carbs, high cal, high fat.

Goal of the acute phase?

Obtain wound closure through restorative therapy

secondary goal of the emergent phase?

Prevent shock, maintain vital organ perfusion

first degree burn

Redness Pain Mild Edema Blanching

What needs to be done immediately for all frost bite?

Remove clothing and jewelry Immerse in water bath (102-108 degrees)

What is the first thing you do for a electrical burn? second?

Remove the electrical source Stabilize Cervical Spine

Stage III - Rehabilitative = Whats important?

Restorative phase Formally begins 2 weeks- 8 months after burn First day of burn injury

Stage I - Emergent = whats important?

Resuscitative phase= Hypovolemic Shock Edema

What is the Major cause of death with burn victims?

SEPSIS. Pt is stable, then you focus on the wounds.

common causes of SUPERFICIAL partial thickness burns

Scalds, flash burns, or brief contact with hot objects usually causes superficial second-degree burns.

Immune System effect of burns

Skin is compromised, at risk for infections. Longer you're under stress, the immune system decreases.

Radiation burns are from exposure to?

Sun&radiation therapy

Waxy pale yellow to blue mottled skin Blistering Numbness, tingling Crunchy and Frozen feeling

Superficial Frostbite

difference between superficial and deep partial thickness burns

Superficial partial-thickness burns involve the epidermis and the superficial dermis. These burns are very painful, and blister formation is common. If the blisters rupture, the wound is moist and erythematous. After applying pressure, these burns blanch and sensation remains intact. DEEP partial thickness burns involve the epidermis and most parts of the dermis, leaving few intact skin appendages and nerve endings. These burns often appear waxy white with cherry red elements representing coagulated dermal elements. Spontaneous healing may require up to six weeks and is often associated with hypertrophic scarring and joint contractures.

Functions of the skin include:

Temperature Regulation Protection Sensory Function Cosmetic

tissue damage internally that you can't see even though the pt seems fine(lightning)

The iceburg effect**

dermal layer

The outermost layer, directly beneath the epidermis

how do SUPERFICIAL partial thickness heal?

These burns heal by reepithelialization from adjacent unburned skin and intact epidermal skin appendages (hair follicles, sebaceous and sweat glands) in two to three weeks with minimal scarring.

complications of circumferential burns to extremities

These burns put one on at risk for problems related to pressure. Leg is burned all the way around, may put them at risk for compartment syndrome. **Edema will cut off blood flow, tournequtte effect**.

What burns need to go to the hospital?

Third degree burns in any age group Partial thickness burns over 10% TBSA Anyone with any Full-thickness burns Involve face, hands, feet, perineum, genitalia, major joints Electrical burns Chemical burns Inhalation injury Burn injury in children in hospitals without qualified personnel or equipment Concomitant trauma Those with pre-existing medical conditions that could complicate situation Those who require treatment that exceeds the capabilities of facility

Fight or Flight response causes what things to happen in the body?

Thirst Ileus Adrenal Gland Stimulation Hepatic Stimulation Vasoconstriction

SUPERFICIAL partial thickness AKA second degree burns involve

This burn involves the deeper dermal layer. Blood supply is reduced.

What do you for the fluids ?

Titrate according to the patient's hemodynamic status

What do you need to keep the urine output above for a burn?

Urine Output- 0.5-1mL/kg/hr (30-50ml/hr)

stage II acute phase

Wound Healing Phase Usually begins 48-72 hours after time of injury Fluid mobilization & Diuresis Begins

FULL thickness burn

a burn in which all the layers of the skin are damaged. There are usually areas that are charred black or areas that are dry and white. Also called a third-degree burn.

Lactated Ringer's fluid is

also known as sodium lactate solution and Hartmann's solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure.

What is one of the biggest issues with amputation of a limb(think leg amputation)

are at risk for contractures based on location

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment, the nurse would expect to find which of the following symptoms? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

b. The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

Circumferential Thorax

burns around the chest cavity can lead to breathing problems, problems with pressure, resp status will be compromised, which will cause more resp problems.

Circumferential burns to extremities

burns that wrap around the extremitiy

The SNS also stimulates adrenal gland which...

chetacolomines released, will cause increased glucose, vasoconstriction in periphery to shunt blood to heart, increased BMR

Lund-bowder is for

children(Takes head/body ratio into consideration)

Issue with chemical burns

destroy tissue and continue to destroy tissue up to 72 hrs unless they are neutralized.

Superficial burn(AKA 1st degree) Involves injury to the ____________________

epidermis.

A fasciotomy is a surgical incision into the

fascia

Why do you use Albumin?

helping to draw fluid from the body into the blood vessels, helps with 3rd spacing

GI: System effect of burns

ileus because of SNS, at risk for stress ulcer. Can develop "curling uler",

What is third spacing and why is it dangerous?

intravascular volume leaves and enters tissues Decrease IV volume. Can lead to hypotension, tachycardia, and decreased CO/urine output; form of shock.

What type of positioning would you do to help prevent contractures for a leg amputation?

lay them on their belly for at least 30mins a day

Electrical burns are classified

on voltage (high or low).Exposure to alternating or direct current Alternating- electric/utility wires Direct- lightning, defibrillator

Hypertrophic scarring

overproduction of collagen that stays within the confines of the original wound

DEEP full thickness burn

rare burn that extends into underlying muscle and bone; aka- fourth degree burn.

Thermal burn is a

result of contact with a hot substance (liquid, solid, steam, and flame). The longer the skin is in contact with the hot surface, the deeper the wound.

joint contractures

result of stiffness or constriction in the connective tissues(skin) of your body. This can occur in your muscles, tendons, ligaments, and skin

how the blood supply in superficial burns?

the blood supply is still intact.

assessment findings for superficial burns

they have mild-severe erhythema NO blisters will blanche if you press on it

After amputating the limb with frost bite, what type of pain medication do you need to give?

tx pain for phantom pain, give neuropathy pain meds, for post op pain give opioids(pain on incision site)

healing time and tx

will DEF scar. Takes 3-6 weeks to heal, most often need skin grafts. hypertrophic scarring and joint contractures possible.

Dry chemical?

wipe it off. Remember PPE**

If someone inhales really hot steam or aspirate hot liquids can they get thermal burns?

yes, they can cause internal burns. Liquids can cause worse burns (grease, oil), because of higher boiling points. Will have more severe burn because the liquid is hotter.