H476 Final Exam: New Material

Burn Wound Characteristics: Rule of Nines - Percentage of TBSA - Patient palm is ____% - Infant/child head is ______% while adult head is _____% - Anterior torso= ______% - Posterior torso = _____% - Each arm = _____% - Each leg = _____% - Genitalia+ _____%

1, 18, 9, 18, 18, 9, 18, 1

BURN CENTER TRANSFER CRITERIA - Partial thickness > ____% TBSA - ______-________ _______ - Burns on ________, ________, ________, _____________, _____________, and ________ - ___________ or ___________ burns - _____________ injury - _______________ - Associated __________

10, full-thickness burns, face, hands, feet, genitalia, perineum, joints, electrical, chemical, inhalation, comorbidities, trauma

Esophageal and Abdominal Varices - The client has ___________ _____ - The client is __________ ________ - The blood needs somewhere to go - Formation of esophageal and/or abdominal varices occurs - Further shunting, possibly along with impaired ____________ ___________ can cause bleeding of the same - Medical emergency!!

portal HTN, shunting blood, clotting factors

Fulminant Hepatic Failure: Presentation - Symptoms quickly and ____________ worsen - _____________, insomnia, __________ - Decreased ________ and severe _________ - ______________ - Chills, __________ and ___________, ____________, sudden ________ _________

progressively, hyperexcitability, lethargy, LOC, coma, convulsions, nausea, vomiting, jaundice, high fever

Hepatorenal Syndrome - Liver failure that is accompanied by ________ __________ - Cause not fully understood, usually with ____-______ _________ and ________, ___________ __________, and low _________ - _________ _________ down and ____________ up quickly - Treatment not usually effective, so outcome is very poor - Can use _________ or ___________, and even ___________ if liver may recover

renal failure, end-stage cirrhosis, ascites, portal hypertension, albumin, urine output, creatinine, fluids, dialysis, hemodialysis

Cirrhosis Inflammation --> Increased _________ --> Poor ________ _______ --> Hepatocyte death/________ tissue replacement

resistance, blood flow, fibrin

BURNS: AREAS OF SPECIAL CONCERN - Facial burns: Risk of ___________ injury, ______ hygiene; promote healing; do not _______ ET tube; leave _________ and _______ intact (protective against bacteria, shave other facial hair) - ______: Prevent infection and breakdown; all cartilage, meds that can penetrate cartilage and help it heal: ____________ - _____: Ophthalmology consult as needed, keep moist with ______ _______ - Hands, feet or major __________: adequate __________, maintain function; wrap fingers like a _________ to prevent webbing - Genitalia and perineum: meticulous wound care to prevent ________, _______ ______

respiratory, oral, tape, eyebrows, eyelashes, ears, Sulfamyalon, eyes, eye drops, joints, circulation, glove, infection, rectal tube

Varices: Endoscopic Procedures - ___________: Varices are injected multiple times in different endoscopic procedures, several days apart, resulting in ____________ of the varices - ______________ _______ _________: Placing a rubber band at the base of the varices, cutting off its blood supply, it ____________ and falls away

sclerotherapy, decompression, endoscopic band ligation, necroses

BURNS: INFECTION - Due to ______ loss - Decreased __________ response - Overabundance of ______________ response - ____________ state* - Prevent __________ (try to make sure their is occlusive central line dressing)

skin, immune, inflammatory, hypermetabolic, CLABSI

Phases of Burn Care: Resuscitative Phase (PREHOSPITAL) - ________ the _________ __________! - Identify life-threatening injuries - ABCs and ________ ________: always stabilize, especially if trauma - Oxygen at ________%, ___________ if needed (especially if suspected inhalation injury) - Assess circulation: pulses, cap refill, blanching - Assess for additional trauma: _______ injuries, _____________, __________, cardiac ____________ - Minimize time on the scene - Remove patient from thermal source - _________ to prevent __________ (cling wrap, sheet; don't overheat which would _________ further) - Remove __________, belts, clothing (metal retains heat and continues burn damage; if clothing does not come off easily, _________ ____ _______; stop burning process with _______ water lavage OVER clothing; not ice water which could cause vasoconstriction) - Scalds, tar, asphalt --> ________ _________

stop, burning process, cervical spine, 100, intubate, ortho, hemothorax, pneumothorax, contusion, cover, hypothermia, vasodilate, jewelry, leave it on, cool, cool water

Burns that only come down partially through dermis; heals in 7-10 days

superficial partial thickness 2nd degree

Phases of Burn Care: Resuscitative Phase: Assessment Cardiovascular - Assess for fluid volume status - Vital signs: ___________ - Prevent _______ loss: Blankets, wrap Neurological - Changes in _______ Renal - Accurate ________ _______ w/_______ _________ (fluid resuscitation, diuresis) GI - Assess for _________ __________ Integumentary - Document extent of injury - Measure _________ of burn (rule of 9, patient palm method) Psychosocial - Assess response to injury - Pain assessment

tachycardia, heat, LOC, urine output, foley catheter, occult bleeding, percentage

What vaccine should all burn patients have

tetanus

electrical currents cause

tetany

What are the three types of burns

thermal, electrical, chemical

Burn Physiologic Response: Pulmonary - __________ __________ __________ (temporary): ___________ from cardiac/pulmonary system - Decreased ________ ____________ (__________ __________ worsens this) - Concern for ________

transient pulmonary hypertension, vasoconstriction, lung compliance, fluid resuscitation, ARDS

Hepatic Encephalopathy: Progression 1. ________, _________ speech, impaired _________-__________ 2. Drowsiness, _________, loss of ___________ control 3. Extreme ___________ and ___________ 4. _______, ____ alterations, NO _______ ____________

tremors, slurred, decision-making, asterixis, sphincter, confusion, somnolence, coma, GI, pain response

Cirrhosis: Presentation - Loss/impairment of liver in _____________, __________, and __________ functions - Leads to ____________ _______, impaired metabolic processes, impaired bile formation/flow

vascularity, secretory, metabolic, portal HTN

Cirrhosis: Initial Presentation VAGUE - Weakness - Fatigue - Anorexia - _________ _________ - _________ and ________ - Change in _________ ___________

weight loss, nausea, vomiting, bowel habits

Inhalation Injuries _____x higher risk of mortality - Inhalation of hot ________, chemical ________, and products of ______________ __________ Carbon monoxide and cyanide poisoning - Carbon monoxide has _____x > affinity for Hgb than O2 - SpO2 and PaO2 may look fine due to ___________ Hgb with O2; not reading carboxyhemoglobin molecules - Cannot rely on these measures; look at patient ___________ (cyanotic, RR, WOB, retractions, LOC, ETCO2 monitor) CLASSIFICATION - __________ injury d/t exposure to toxic gases - __________ injury (sinuses, larynx, pharynx, nose) --> ___________, ______ cough, burns to face/around mouth - ____________ injury (________ in sputum)

25, smoke, toxins, incomplete combustion, 200, bounded, presentation, systemic, supraglottic, stridor, dry, subglottic, soot

A 60 kg patient was splattered with oil that ignited causing partial thickness burns to her anterior arms and anterior torso. Calculate the total fluid resuscitation required for the first 8 hours.

3,240 mL (4.5% anterior arm 1 + 4.5% anterior arm 2 + 18% anterior torso = 27% TBSA. 60 kg x 4 mL x 27% = 6,480 ml/2 = 3240)

BURN TREATMENT: RESUSCITATIVE PHASE Fluid guidelines for adults - Maintain urine output of ____-____ ml/hr - Place IV access in ____-______ areas - Hold __________ for ___-____ _______ after injury - ________ injury requires more fluids

30-50, non-burned, colloids, 8-12 hours, inhalation

A 143 pound patient suffered burns on the left anterior torso, the anterior portion of the left leg, and the left arm in a house fire at noon. The client has arrived at the emergency room at 1600. Calculate the total needed to be given in the four hours after admission.

3510 mL (143 lbs / 2.2 kgs = 65 kgs TBSA = 9% (left anterior torso) + 9% (anterior portion of left leg) + 9% (left arm) = 27%65 kgs x 4 mL x 27% TBSA = 7,020 mL / 24 hours7, 020 mL / 2 (for first 8 hour total) = 3,510 mL total fluid in first 8 hoursThe burn occurred at noon, the client arrived in ED at 1600, 4 hours later. That means the 8 hour total must be infused in 4 hours. The 8 hour infusion total begins from the time of the burn. Therefore, 3,510 mL in the next four hours.)

How much TBSA would the posterior portion of a patient's left arm be

4.5

A 90 kg patient ignited his mattress while smoking causing partial and full thickness burns to the posterior torso and back of both legs. He has received the first 8 hours of fluid resuscitation. What is the hourly IV rate for the next 16 hours?

405 mL/hr (TBSA = 18% (posterior torso) + 9% (back of leg #1) + 9% (back of leg #2) = 36%90 kgs x 4 mL x 36% TBSA = 12, 960 mL / 24 hours12, 960 mL / 2 (for first 8 hour total) = 6,480 mL infused in first 8 hours, leaving 6,480 mL to be infused in next 16 hours6,480 mL / 16 hours)

BURNS: ACUTE PHASE - Begins _____-_____ _______ after injury - Continue with assessments performed during resuscitative phase Focus of interventions is to: - Promote ________ ________ - Prevent complications: ______, ________, renal failure, _________, stress ________ - Improve function of body systems (systemic response to burn injury)

48-72 hours, wound healing, ARDS, infection, contractures, ulcers

Alternating current (A.C) is ____ times more dangerous than Direct current (D.C). The frequency of the alternating current is the main reason for this severe effect on the human body. The frequency of 60 cycles is in an extremely harmful range. At this frequency, even a small voltage of 25 volts can kill a person.

5

Mortality rate for critically ill clients with end-stage liver disease

50-100%

A 220 pound patient accidentally stepped into a vat of tar receiving full thickness burns on both legs. Calculate the hourly IV rate of the fluid replacement he will require for the first 8 hours.

900 mL/hr (220 lbs/2.2 = 100 kg. TBSA = 18% + 18%= 36%; 4 mL x 100 kg x 36% TBSA = 14,400 mL/2 = 7,200 for first 8 hours / 8 hours = 900 ml/hr)

low voltage electric burn

< 1000

High voltage electric burn

> 1000

Burn Assessment: Resuscitative Phase Monitor serum electrolytes - Sodium: Give _____ - Potassium: _____ - BUN: ______ d/t decreased kidney perfusion - Glucose: _______ (Stress response) - Lactate: _______ (muscle breakdown, lack of perfusion)

LR, low, high, high, high

Which types of hepatitis can be curable with treatments

A, B

Calculate the volume of IV fluid needed for the first 8 hours after burn injury: 60 years old, 82 kg, 42% TBSA. A. 3,444 mL B. 6,888 mL C. 13,776 mL D. 19,456 mL

B

alternating current is more dangerous than direct current (T/F)

T

Which types of hepatitis can become chronic

B, C, D, G

What is an appropriate intervention in the prehospital setting in the management of an unconscious patient who was pulled from a house fire. His vital signs are BP 100/82 mm Hg, HR 122 beats/min, RR 26 breaths/min, SpO2 100%. A. Monitor vital signs every 15 minutes. B. Cover the patient with warm blankets. C. Apply 100% humidified oxygen- house fire D. Place the patient in a side-lying position.

C

Hepatic Encephalopathy - Derangement of the ______ (not fully understood, but involves interference d/t __________ - Altered (lowered) ______ --> severe ________ - Address the reason it is occurring (__________, _____ _________, ____________ imbalances) - Limit ___________ (_____-____ _______ per day) - Give ___________ (acidic, laxative) - Possible ____________ (bad for the kidneys, kills good flora, slows protein breakdown) - Possible _____________/Flagyl (not often, not good compliance) - Avoid/change meds that are hard on the liver

CNS, ammonia, LOC, coma, infection, GI bleed, electrolyte, protein, 20-40 grams, lactulose, neomycin, metronidazole

BURNS: PAIN CONTROL - Adequate, accurate assessment tools: _______ - __________, _____ route - ______ may be useful - Do not leave in most comfortable position (___________) - Nonpharmacological strategies

CPOT, opiates, IV, PCA, contractures

Impaired synthesis and destruction of clotting factors in liver failure major complication

DIC

Acidic burns are more severe than alkaline burns (T/F)

F

Burn: Physiologic Responses - ________ shifts - Cardiovascular - Immune - Pulmonary - Renal - GI - Metabolic

Fluid

Phases of Burn Care 1. __________ Phase: ABCs, _______, prevent _______ ________ 2. ________ Phase: Natural _________ around 48 hours, wound _________ 3. ___________ phase: _________, ______, minimizing scarring, can overlap with acute, may be at rehab facility

Resuscitative, fluids, burn shock, acute, diuresis, closure, rehabilitation, grafting, ROM

Resuscitative Phase: Fluids - Based on % ________ - IV fluid resuscitation is instituted for patients with greater than _____% TBSA burned - Consensus formula (Parkland): 20% and higher: _____ _____ x _____ x _________% - Administer ______ of total fluids during first ____ ________ from time of injury - Administer _______ over the next ____ _______ from time of injury

TBSA, 20, 4 mL, kg, TBSA, half, 8 hours, half, 16 hours

Types of Cirrhosis 1. ____________: ________ liver, ________ tissue (acetaldehyde, toxic byproduct) 2. ____________: decrease in bile flow (_________ of the ________) 3. __________: decreased oxygenation of the liver from severe _______-_______ ________ _________ 4. _______-__________: ___________, chemicals, metabolic disorders, ______________ medications

alcoholic, fatty, fibrotic, biliary, fibrosis, ducts, cardiac, right-sided heart failure, post-necrotic, infection, hepatotoxic

Cirrhosis - Usually brought on by _____________ (overworking the liver) - Can have ________ _______ - Inflammation leads to poor blood flow d/t increased resistance leading to cell death - As the cells attempt to regrow, fibrous tissue builds, changing the landscape of the liver further, causing blood flow resistance with less healthy liver tissue

alcoholism, fatty deposits

Type of chemical burns

alkaline/base, acid, organic compounds

Main 4 complications with liver failure

ascites (swelling in peritoneum, abdominal compartment syndrome), hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome

Hepatic Failure: Manifestations - Activity intolerance - ___________* - ____________* - Edema (no _______ pressure) - _____________ ____________ - Abdominal changes (pain, N/V, malnutrition, _________ changes) - ____________ (ascites pressing on diaphragm) - __________ (dyspnea, decreased RBC formation, low perfusion d/t low oncotic pressure and portal HTN)

ascites, jaundice, oncotic, spider angiomas, bowel, dyspnea, hypoxia

BURNS: NUTRITION - High _________ and high ___________ - Feed through ________ _______: Corpak - Start feeding within _____ ________ if possible - Monitor for _________ - Administer _______ _________ or _________ _________ to counter hypermetabolism ***______________ (steroid that helps promote muscle and tissue growth)

calorie, protein, small bowel, 24 hours, ileus, beta blockade, anabolic hormones, oxandrolone

__________ _______ in the middle of a hepatic lobule takes nutrient rich and oxygen poor blood to the hepatic vein which then eventually takes blood to the ________

central vein, heart

Hepatits: Initial Presentation - Often _______________ Prodromal - Anorexia - ___________ & __________ - ___________ pain & ____________ - ____________

asymptomatic, nausea, vomiting, abdominal, distension, fatigue

examples of acids that can cause burns (3)

bathroom cleaners, rust remover, pool chemicals

Impaired Bile Formation & Flow - If the liver cannot metabolize _______, the client has ____________ buildup to the point of staining the _______ (jaundice) - Usually seen in clients with bilirubin > _____ mg/dL Often seen on hands. Not in early stages

bile, bilirubin, skin, 3

Hepatitis can be spread through contact with __________ and its products, _________, _________, ___________ _________, and direct contact with infected objects

blood, semen, saliva, mucous membranes

Hepatopulmonary Syndrome - Paired with either or both ________ _________ ________ and _________ ______________ - Intrapulmonary vascular __________ can lead to severe __________ - The "triad" is ________ _________, increased _________-__________ _________ __________, and intrapulmonary _________ __________ - V/Q __________ occurs d/t pulmonary capillary vasodilation - Give __________, possible ________, needs _________ __________

chronic liver disease, portal HTN, dilation, hypoxia, liver disease, alveolar-arterial oxygen gradient, vascular dilation, mismatch, oxygen, TIPS, liver transplant

BURN TREATMENT: RESUSCITATIVE PHASE Peripheral Circulation - ____________ ______-_________ burns: Risk for ___________ ____________ - Neurovascular assessment - 6 Ps: ____________, ____________, ____________, ____________, ____________, and ____________ - __________ or ___________ to relieve the pressure

circumferential full-thickness, compartment syndrome, pulseless, poikilothermic, pallor, pain, paresthesia, paralysis, escharotomy, fasciotomy

Burns: Intraabdominal Hypertension Causes - ____________ ________ injury - ______________ _________ ______________ Defined as IAP >= _____ mmHg Becomes abdominal compartment syndrome when IAP >= _____ mmHg S&S: ________ abdomen, decreasing ________ ________, _________, __________

circumferential torso, aggressive fluid resuscitation, 12, 20, tense, urine output, hypoxia, hypercapnia

Patient presents with weakness, fatigue, anorexia, weight loss, nausea, vomiting, and change in bowel habits. What should nurse suspect

cirrhosis

Bleeding Varices - This can occur WITHOUT a known history of ___________ - Initial treatment is the same - STOP the bleeding - Treat hemodynamic instability - Protect the airway - Empty the __________ - Find cause of bleeding and treat - _____________: Decreases sphlanic blood flow and reduces _________ pressure (watch blood __________!!) - ____________: ADH lowers portal pressure through vasoconstriction of the sphlanchic arteries, does not seem to increase survivability and comes with risks, including ______, _____________, worsening heart failure, HA, tremors, decreased LOC, vertigo, GI effects, even localized gangrene

cirrhosis, stomach, octreotide, portal, glucose, vasopressin, HTN, dysrhythmias

acid burns can cause a specific pattern of burn called

coagulation necrosis

the process in which an acid, while destroying tissue, forms an insoluble layer that limits further damage.

coagulation necrosis

Burn Wound Characteristics: Zones of Thermal Injury - Zone of _____________: Dark red area with _________ tissue (not salvageable, t(x) involves saving other zones) - Zone of _______: ________ _________ therapy: Water, oil, and antimicrobial agents to revitalize this zone and other zone) - Zone of ____________

coagulation, necrotic, stasis, nano emulsion, hyperemia

Types of electrical burns (2)

current, lightning

Burn Physiologic Response: Renal - __________ __________ ___________ - Electrolyte imbalances: _____________ (watch for dysrhythmias) - Diuresis should begin _____ _______ after fluid resuscitation

decreased urine output, hypokalemia, 48 hours

Acute Hepatic Failure: Labs - Albumin (___________ d/t altered synthesis and hemodilution/ascites) - ALT/AST: ___________ - Bilirubin (serum & urine): ___________ - PT/PTT: _____________ - Ammonia: ___________ - Cholesterol (bile alterations): ____________ - Dilutional ___________ or _________ (low albumin, high ADH/aldosterone) - ___________ d/t diuretics - Increased ______ - CBC (H&H) may be decreased d/t variceal bleeding

decreased, increased, increased, prolonged, increased, increased, hyponatremia, hypokalemia, hyperkalemia, ADH

Burn that goes all the way down to base of the dermis; heals in 2-4 weeks

deep partial thickness 2nd degree

BURNS: SKIN GRAFTS - Grafts for _______ _________-________ or _______-__________ burns - ___________: comes from patient; only PERMANENT SOLUTION; normally work up from below grafts - __________: comes from a cadaver - __________: comes from an animal - __________ (nonmeshed) grafts used on face and hands - __________ grafts for large surface areas

deep partial-thickness, full-thickness, autograft, allograft, xenograft, sheet, meshed

lightning burns have _______ current; _________ hold onto heat longer than _____

direct, bones, fat

Factors that increase thermal burn severity - ____________ of time skin is in contact with skin - ______________ of heat source - ___________ of _________ (% TBSA that encountered heat source) - ________ (elderly have thinner skin, less thermoregulation, decreased _____________; infants have > % __________, decreased reflexes)

duration, temperature, amount, tissue, age, reflexes, TBSA

Burn Wound Characteristics: Depth - First degree: Superficial/________ only; heal themselves within ___-____ ______ - Second degree: ________ thickness/ _________ + _________; If ____% TBSA 2nd degree: BURN CENTER; blood vessels burned, could cause bleeding - Third degree: ______ thickness/___________ + ___________ + ________ (possibly + _______/_________/_________) - Minimally contains _____ tissue - Nerve _______ is burned, no _______ - May also include fascia, muscle, and bone (could be __________ chemical burn)

epidermis, 3-5 days, partial, epidermis, dermis, 10, full, epidermis, dermis, SQ, fat, muscle, bone, SQ, root, pain, alkaline

3 types of thermal burns

flame, scalding, direct contact (with heat source)

Acute Liver Failure: Treatment - Cardiac: _________ - Risk for bleeding: Reduce _______, may have to replace - Decrease meds metabolized by liver (acetaminophen, _____________) - _________ system: Attempt at liver dialysis, cannot do all liver functions (just detoxification) - Possibly new artificial liver - _________ ___________ ****

fluids, pokes, propofol, MARS, liver transplant

Cirrhosis - ________ or ________; inflammation and ________ - __________ tissue instead of healthy hepatocytes, can be _______ or _____-________ - ___________, __________, ________, or _______-__________ - ___________ makes it so hepatocytes CANNOT regenerate - Portal HTN that can cause ___________ or _____________ (mesenteric artery HTN)

focal, diffuse, edema, fibrous, fatty, non-fatty, alcoholic, biliary, cardiac, post-necrotic, fibrin, splenomegaly, varices

examples of organic compounds that can cause burns (4)

gas, kerosene, disinfectants, petroleum

BURNS: ACUTE PHASE INTERVENTIONS - _____________ monitoring in the _______ (_________ ________ line, shoot for ____ and above, possible PA cath) - Gastric ____, ________ blood - Prevent __________: bear hugger, cling wrap, warm fluids, set room temperature to ___-____ degrees - _______ prophylaxis: _____, _________, heparin (in good, viable tissue) - Maintain joint function and mobility: ________ or _________ (PT) within first ____ _______ to prevent contractures

hemodynamic, ICU, central venous, 6, pH, occult, hypothermia, 80-90, VTE, SCDs, enoxaparin, AROM, PROM, 24 hours

hepatic triad

hepatic artery, hepatic portal vein, bile duct

The liver receives a blood supply from two sources. The first is the __________ _______ which delivers oxygen rich blood from the general circulation. The second is the hepatic ___________ _______ delivering deoxygenated, nutrient rich blood from the small intestine and spleen. The ________ __________ ________ delivers bile from the liver to the intestine for digestion.

hepatic artery, portal vein, common hepatic duct

Inflammation of the liver

hepatitis

Patient presents with anorexia, nausea, vomiting, abdominal pain, distension, and fatigue. What should the nurse suspect?

hepatitis

Hepatitis - Killing ____________ or lowering blood flow d/t ______________/_______ (backup into inferior/superior _________ artery/________ vein)

hepatocytes, inflammation, edema, mesenteric, splenic

BURN TREATMENT: RESUSCITATIVE PHASE Fluid guidelines for electrical injuries - Patients with electrical injuries need ________ volumes of fluids - Keep urine output at ____-___ mL/hr - Risk: _____________ (rhabdomyolysis, burning under the skin)

higher, 75-100, myoglobinuria

What assessment findings could indicate smoke inhalation (5)

hoarse voice, singed nose hairs, grey sputum, facial burns, wheezing/stridor

Portal Hypertension: Pathophysiology ________________ ____________ - Blood is __________, causing ____________ cardiac output - ____________ is present, so there is decreased __________ despite increased output - This is also known as ________-__________ ___________ - _______, pulmonary ____________, decreased organ perfusion - Starts with ______, __________ skin, ____________ pulses, then BP _________ and ___________ are common - ____________ - Esophageal and gastric _________

hyperdynamic circulation, shunted, increased, vasodilation, perfusion, high-output failure, JVD, crackles, HTN, flushed, bounding, decreases, arrhythmias, splenomegaly, varices

Burn Physiologic Response: Metabolic - Initially decreased organ function d/t ___________ ____________ phase - Begins as _________ __________ is completed - ______________ - Results of inflammatory __________/_____________/___________ being released - Lasts ___-_____ _______, even _______ - Metabolic demands _____-_____ % above normal basal rate - Body is continuously trying to ________ - Weight ________, need to increase caloric intake - May give __________ __________ to help suppress this hypermetabolism

hypovolemia, hypermetabolic, fluid resuscitation, hyperthermia, mediators, catecholamines, cortisol, 9-12 months, years, 100-200, heal, loss, anabolic hormones

Phases of Burn Care: Resuscitative Phase; hospital - Assess for ___________ and _______ _________ ________ - Watch patient presentation, not just SpO2 and PaO2 (WOB, cyanosis, LOC, signs of perfusion) - Treat carboxyhemoglobin with _______% ___________ _______; decreases ______-______ of carboxyhemoglobin from ____ hour(s) to _____ hour(s) - Assess for direct injury: Pneumothorax; hemothorax - Maintain _________ ________ precautions (pt loses diaphragmatic pacemaker at _____)

hypoxemia, carbon monoxide poisoning, 100 humidified O2, half-life, 4, 1, cervical spine, C4

Burn Physiologic Response: Immune - Over abundance of ___________ __________ and ___________ mechanisms: Increased capillary membrane permeability - Overstimulation of __________ ______ _________: _____________ response from burn - Decreased production of _________ T cells, __________ T cells, and __________ - More susceptible to _________

inflammatory mediators, clotting, suppressor T cells, immunosuppressive, Killer, Helper, leukocytes, sepsis

Burn Physiologic Response: Cardiac - Loss of ____________ volume : Decreased __________ ________; _________ and ___________ which in turn causes increased ____________ - ____________ __________ with __________ inotropic effect: Decreased __________ of the heart - Cardiac output increases _____ ________ after injury, leading to ___________ as fluid naturally comes back into vascular system

intravascular, cardiac output, tachycardia, vasoconstriction, afterload, myocardial depression, negative, contractility, 48 hours, diuresis

Burn Physiologic Response: Fluid Shifts - From ___________ to __________ space with inflammatory response that increases ____________ ____________ __________ - Burns > ______% TBSA (does not mean person with less cannot have fluid shifts) - Maximum edema _____-_____ _________ postburn - Exacerbated by ________ ___________: Proteins shifting into tissues, so lymphatic tissue becomes overwhelmed w/large protein molecules, causing more edema - _________ __________: Hypovolemic, hypotensive, and tachycardia, low ________ (___-___), cardiac output ___________

intravascular, extravascular, capillary membrane permeability, 20, 24-48 hours, lymphatic drainage, burn shock, CVP, 2-3, decreased

BURN LABS Hematocrit <15%: as third-spaced fluid reenters the __________ compartment or with concomitant traumatic injury >60%: ____________ Serum lactate >2.2 mEq/L: ___________ __________; should decrease if fluid resuscitation is adequate Potassium <2.5 mEq/L: Tissue damage; assess for _____________ >6.6 mEq/L: May increase as potassium reenters cells Sodium ≤110 mEq/L: Levels approach the sodium concentration of ______ being administered ≥160 mEq/L. May increase with inadequate fluid replacement or with ________ Blood urea nitrogen >100 mg/dL: May increase from catabolism or _________; monitor nutrition and volume status Platelets <20,000/μL: In large %TBSA burns, hypothermia-induced bleeding disorders, or infection White blood cell count <2000/μL: Transient from use of topical ______ sulfadiazine >100,000/μL: with _________

intravascular, hypovolemia, metabolic acidosis, dysrhythmias, fluids, diuresis, hypovolemia, silverw, infection

Phases of Burn Care: Resuscitative Phase: PREHOSPITAL CONTINUED - _______-_______ _____ catheter and ________ - Aggressive _______ __________; do not put IV through burned skin if possible; _______ mL/hr - Pain management with narcotics: _________ is drug of choice; give ______ (predictable, fast pain relief; no risk of vomiting) - Vital signs and baseline assessment: __________! (head injury)

large-bore IV, fluids, fluid resuscitation, 500, morphine, IV, neuro

Electrical burns follows path of

least resistance

Hepatitis: Presentation - ______-_______ _________ - ___________ - ___________/_________ __________ Leads to impaired metabolic processes, impaired bile formation/flow Patients do not generally have portal HTN

low-grade fever, jaundice, enlarged/tender liver

examples of alkaline substances that can cause chemical burns (3)

lye, wet cement, fertilizers

Liver Functions 1. ___________ carbs, fats, and _________; including ___________ (transportation of nutrients to cells), ____________ (blood clotting), and ____________ (oncotic pressure in the intravascular system) 2. Synthesis and destruction of ____________ ___________ 3. Fighting infection - ____________ 4. Metabolism of ________ and vitamins (_____ production) 5. Detoxification of blood: __________ to ________, hormones (especially __________ and ______) 6. ___________ regulation; stored hepatic __________ and ________________ (might not be able to use sugar stored in liver)

metabolizing, proteins, globulin, fibrinogen, albumin, clotting factors, detoxification, iron, RBC, ammonia, urea, aldosterone, ADH, glucose, glycogen, gluconeogenesis

Burn Physiologic Response: GI - Decreased _________ - ___________ ________ - ________ _______: Give _____s

motility, paralytic ileus, stress ulcers, PPI

BURNS: WOUND CARE __________ __________ therapy - Consists of a _________, __________ tubing, and ___________ dressing Creates negative pressure to: - Remove ________/excess ________ - Promotes _______________ to area - Stimulates __________ - Provides a ________ ________ for wound healing May be used on wounds or ________ *Can't _____________ the wound

negative pressure, sponge, suction, occlusive, edema, fluid, revascularization, perfusion, closed system, grafts, visualize

BURNS: WOUND CARE - Remove __________ tissue - Promote re-epithelialization and wound healing - __________ room prior to wound care (prevent hypothermia) - Clean and ________ wounds --> mild ______, scalpel, forceps, tweezers - ____________: jets to wash away debridement - Application of anti-microbial _________-_______ agents - Open versus closed method

nonviable, prewarm, debride, soap, hydrotherapy, silver-based

Non-alcoholic fatty liver - Liver damage _____ caused by __________ - __________, __________, hepatic resection, starvation, _______ - This causes fatty deposits which are different than the fibrous tissue in cirrhosis but impede the liver just the same

not, alcoholic, obesity, diabetes, TPN

Ascites - Fluid in the ____________ - ______, low __________ intravascularly, ________ and water imbalances - Pushes up on the ____________ - _________ the abdomen at regular intervals and watch for abdominal compartment syndrome - Watch for difficulty with breathing (rate, depth, dyspnea, DOE) - ______ _______ (reduce metabolic needs) - Position in ______-_____________ - Low _________, ________-restricted diet - _____________ (cautiously); already intravascularly dry - _______________ _________ (LeVeen, Denver with active pump) --> not for _______ ascites

peritoneum, ADH, albumin, sodium, diaphragm, measure, bed rest, semi-Fowler's, sodium, fluid, diuretics, peritoneal shunting, acute