Tissue Integrity/Burns
acute phase pain management
2 kinds of pain continuous background pain - IV infusion of an opioid - or slow-release, twice-a-day oral opioid treatment-induced pain - analgesic and anxiolytic
A pt is admitted to the burn unit w/ second- and third-degree burns covering the face, the entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%
22.5%
Parkland (Baxter) Formula
4 mL * kg * TBSA application: - 1/2 total in 1st 8 hr - 1/4 total in 2nd 8 hr - 1/4 total in 3rd 8 hr
Which pt should the nurse prepare to transfer to a regional burn center? 25-yr-old pregnant pt w/ a carboxyhemoglobin level of 1.5% 39-yr-old pt w/ a partial-thickness burn to the right upper arm 53-yr-old pt w/ a chemical burn to the anterior chest and neck 42-yr-old pt who is scheduled for skin grafting of a burn wound
53-yr-old pt w/ a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.
pt w/ DM or peripheral vascular disease
@ high risk for poor healing and gangrene, especially w/ foot and leg burns
When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)? Select all that apply. The exercises are the only way to prevent contractures. Active and passive ROM maintain function of body parts. ROM will show the patient that movement is still possible. Movement facilitates mobilization of leaked exudates back into the vascular bed. Active and passive ROM can only be done while the dressings are being changed.
Active and passive ROM maintain function of body parts. ROM will show the patient that movement is still possible. Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? Administer 100% humidified oxygen. Teach the patient deep breathing exercises. Encourage the patient to express his feelings. Assist the patient to a high Fowler's position.
Administer 100% humidified oxygen Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.
Lund-Browder Chart
An accurate way of calculating/estimating extent of burns, used especially for children, based on age for irregular- or odd-shaped burns, the pt's hand (including fingers) is approximately 1% TBSA the extent of the burn is often revised after edema has subsided and a demarcation of the zones of injury has occurred
Rehabilitation phase
Begins when wounds have healed and the patient is engaging in some level of self-care can occur as early as 2 weeks or as longs s 7-8 months after a major burn injury
emergent phase nsg/interprofessional mgmt
- 2 large-bore IV lines for >15% TBSA - crystalloid (LR, NS) - colloid (albumin) - >30%: central line for fluid and drug administrations and blood sampling should be considered - arterial line for frequent ABGs or invasive BP monitoring - Parkland (Baxter) formula for replacing fluids - colloidal solutions may be given - administration is recommended after the first 12-24 hrs post burn, when capillary permeability returns to normal or near normal
conditions leading to burn shock
- @ time of major burn injury, capillary perm is ↑ - all fluid components of the blood begin to leak into the interstitium, causing edema and ↓ blood vol - RBC and WBC do not leak - Hct ↑, blood becomes more viscous - combo of ↓ blood volume and ↑ viscosity produces ↑ peripheral resistance - burn shock, a type of hypovolemic shock, rapidly enduses, and if it is not corrected = death can result can begin as early as 20 minutes post burn
Emergent phase - patho cont'd
- RBCs are hemolyzed by direct insult of burn injury and by circulating factors released @ time of burn - ↑ Hct - commonly caused by hemoconcentration d/t fluid loss - K shift develops 1st b/c injured cells and hemolyzed RBCs release K into extracellular spaces - NA rapidly moves to intersitial spaces and remains until edema formation ends
emergent phase complications - CV
- impaired microcirculation and ↑ viscosity → sludgiing - VTE
pt risk factors
- preexisting diseases - physical weakness renders pt less able to recover - alcoholism - drug abuse - malnutrition - concurrent fractures, head injuries, or other trauma leads to a more difficult time recovering
acute phase clinical manifestations
-Partial thickness wounds form eschar, once eschar is removed, re-epithelialization begins -Full thickness wounds require debridement epithelial buds from the dermal bed eventually close in the wound, which then heals spontaneously w/out surgical intervention, usually w/in 10-21 days margins of full-thickness eschar take longer to separate. As a result, full-thickness wounds require surgical debridement and skin grafting for healing
upper airway injury
-injury to the mouth, oropharynx and larynx -caused by thermal burns or inhalation of hot air, steam or smoke - presence facial burns - singed nasal hair - darkened oral/nasal membranes - hx of being burned in enclosed space - clothing burns around neck chest - blisters, edema - hoareness - difficulty swallowing - carbonaceous/copious secretions - stridor - substernal and intercostal retractions - total airway obstruction
lower airway injury
-injury to the trachea, bronchioles, and alveoli -injury related to length of exposure to smoke and toxic fumes - pulm edema may not appear until 12-48 hrs after burn - manifests as ARDS - pneumonia high degree of suspicion if pat was trapped in a fire in an enclosed space or clothing caught fire presences of facial burns or singed nasal or facial hair dyspnea carbonaceous sputum wheezing hoarseness altered mental status - firber optic bronchoscopy to evaluate lower airway injury
metabolic asphyxiation
Carbon monoxide (CO) poisoning CO is produced by the incomplete combustion of burning materials *Inhaled CO displaces oxygen* -Hypoxia - Carboxyhemoglobinemia - when blood levels of CO are greater than 20% -Death treat w/ 100% humidified O2
acute phase wound care
Daily observation, assessment, cleansing, debridement, and dressing reapplication.
emergent phase nsg/interprofessional mgmt ears
Ears should be kept free of pressure b/c of their poor vascularization and tendency to become infected. The pt w/ ear burns should not use pillows b/c pressure of the cartilage may cause chondritis, and the ear may stick to the pillowcase, causing pain and bleeding raise pt's head using a rolled towel placed under the shoulders, w/ care taken to avoid pressure necrosis
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care (select all that apply.)? Select all that apply. Escharotomy Administration of diuretics IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent
Escharotomy IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.
emergent phase - patho
Fluid and electrolyte shifts: - greatest risk is hypovolemic shock - colloidal osmotic pressure decreases - more fluid shifting out of vascular space into interstitial spaces (third spacing) - normal insensible loss: 30-50 mL/hr - severely burned pt: 200-400 mL/hr - net result of fluid shift is intravascular volume depletion - edema - ↓ BP - ↑ pulse - ↓ urine output
The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? Subcutaneous (SQ) tetanus toxoid Intravenous (IV) morphine sulfate Intramuscular (IM) hydromorphone Oral oxycodone and acetaminophen
Intravenous (IV) morphine sulfate IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 g IV Urine for myoglobulin Lactated Ringer's solution at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours
Lactated Ringer's solution at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.
The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery.
Monitor for signs of complications. Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? Morphine Sertraline Zolpidem Enoxaparin
Morphine Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.
A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure
No pain, waxy white skin, and no blanching with pressure With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
emergent phase nsg/interprofessional mgmt early ROM exercises
PT is begun immediately, sometimes during showering/dressing changes and before new dressings are applied. Movement aids the shift of the leaked fluid back into the vascular bed. Active & passive exercise of body parts also maintains function, prevents skin and joint contractures, and reassures the pt that movement is still possible
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 manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands
Reddening of the skin 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.
electrical burns
Result from coagulation necrosis caused by intense heat generated from an electrical current May result from direct damage to nerves and vessels causing tissue anoxia and death Travels through blood attracted to electrolytes
The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters. Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.
Skin is shiny and red with clear, fluid-filled blisters. Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.
The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)? Select all that apply. Urine output is 46 mL/hr. Heart rate is 94 beats/min. Urine specific gravity is 1.040. Mean arterial pressure is 54 mm Hg. Systolic blood pressure is 88 mm Hg.
Urine output is 46 mL/hr. Heart rate is 94 beats/min. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.
Pain mgmt for the burn pt is most effective when: SATA a pain rating tool is used to monitor the pt's level of pain painful dressing changes are delayed until the pt's pain is completely relieved the pt is informed about and has some control over the mgmt of the pain a multimodal approach is used (sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics) nonpharmacologic therapies replace opioids int eh rehab phase of a burn injury
a pain rating tool is used to monitor the pt's level of pain the pt is informed about and has some control over the mgmt of the pain a multimodal approach is used (sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics)
escharotomy
a scalpel or electrocautery incision through the full-thickness eschar -performed p txfr to burn center, restores circulation escharotomies of the chest wall may be needed to relieve respiratory distress secondary to circumferential, full-thickness burns of the neck and chest
Knowing the most common causes of household fires, which of the following prevention strategies would the nurse focus on when teaching about fire safety? a. set how water temp at 140 F b. use only hardwired smoke detectors c. encourage regular home fire exit drills d. never permit older adults to cook unattended.
a. set how water temp at 140 F
AlloDerm
acellular dermal matrix derived from donated human skin permanent
Adrenocortical insufficiency
adrenal glands do not produce adequate amounts of steroid hormone (cortisol) impaired production of aldosterone (a mineralcorticoid) regulates sodium conservation and potassium secretion, and water retention
rehab phase therapy for contractures
aimed at the extension of body parts b/c the flexors are stronger than then extensors
severity of electrical burns depends on. . .
amount of voltage tissue resistance current pathways surface area duration of flow can be difficult to assess, as most damage occurs beneath skin - iceberg effect
emergent phase nsg/interprofessional mgmt Eye care for corneal burns
antibiotic ointments an ophthalmology examination should occur soon after admission for all pts w/ facial burns periorbital edema can prevent opening of the eyes and can be frightening to the pt. Always check that the pt's eyelashes are not turned inward toward the eyeball. You must provide assurance that the swelling is not permanent instillation of methylcellulose drops or artificial tears into the eyes for moisture provides additional comfort. Apply antibiotic eye ointment for corneal burns or edema as ordered
A pt is admitted to the burn center w/ burns to his head, neck and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? encourage the pt to cough and auscultate the lungs again obtain VS, O2 sat, and a STAT ABG document the findings and continue to monitor the pt's breathing anticipate the need for endotracheal intubation and notify the physician
anticipate the need for endotracheal intubation and notify the physician
Silvadene (silver sulfadiazine)
applied directly to the burned tissue, Silvadene is a synthetic antimicrobial drug produced when silver nitrate reacts w/ the chemical sulfadiazine and has proved both effective and safe in the prevention and tx of infections in burns - monitor for adverse effects - pain, burning, itching use sterile-gloved hand remove previous application before new application monitor for signs of infection avoid sunlight on new skin for several months vit E can be applied after the epidermis is replaced
A therapeutic measure used to prevent hypertrophic scarring during the rehab phase of burn recovery is applying pressure garments repositioning the pt Q2H performing active ROM @ least Q4H massaging the new tissue w/ water-based moisturizers
applying pressure garments
burns to buttocks or perineum
are @ high risk for infection from urine or feces contamination
burns to the ears and nose
are @ risk for infection as the skin is very thin and the underlying skeleton is frequently exposed
burns to hands, feet, joints, and eyes
are of concern b/c they make self-care very difficult and may jeopardize future function
acute phase
begins w/ mobilization of extracellular fluid and subsequent diuresis concludes when: - partial thickness wounds are healed and/or - full thickness burns are covered by skin grafts
assessment of adequacy of fluid resuscitation
best made using clinical parameters urine output is the most commonly used parameter
Integra
bidodegradable dermal layer made of bovine collagen and glycosaminoglycan bonded to silicone membrane permanent
When assessing a patient with a partial-thickness burn, then nurse would expect to find: SATA blisters exposed fascia exposed muscle intact nerve endings red, shiny, wet appearance
blisters intact nerve endings red, shiny, wet appearance
emergent phase clinical manifestation
blisters paralytic ileus shivering altered mental status
matriderm
bovine collagen and elastin matrix permanent
smoke and inhalation injury
breathing noxious chemicals or hot air can cause damage to the respiratory tract airway compromise and pulmonary edema can develop over the first 12-48 hrs
When monitoring initial fluid replacement for the pt w/ 40% TBSA deep partial-thickness burns, which finding is most concerning for the nurse? a. urine output 35 mL/hr b. K 4.5 c. BP 85/60 d. ↓ bowel sounds
c. BP 85/60 adequace of fluid replacement is assessed by urine output & cardiac parameters. Urine output should be 0.5-1 mL/kg/hr. MAP should be > 65 mm HG, systolic BP > 90 mmHG, and HR < 120 bpm. A BP of 85/60 indicates inadequate fluid replacement
allograft (homograft)
cadaveric skin temp - 3 days to 2 wks
alkali burns
can be more difficult to manage than acid burns b/c alkalis adhere to tissue, causing protien hydrolysis and liquefaction alkalis are found in cement, oven and drain cleaners, and heavy industrial cleansers
burned arms
can be wrapped w/ a layer of tubular elastic gauze (Tubigrip) This interim pressure prevents blister formation, promotes venous return, and ↓ pain and itchiness once skin is completely healed and less fragile, custom-fitted pressure garments replace the tubular gauze
location of burn
circumferential burns of extremities can cause circulation problems distal to burn pts may also develop compartment syndrome from direct heat damage to the muscles and subsequent edema and/or preburn vascular problems
emergent phase nsg/interprofessional mgmt wound care - cleansing
cleansing - and gentle debridement, using scissors and forceps, can occur on a shower cart, in a regular shower, or on a pt bed/stretcher by RN and appropriate personnel
pneumonia
common complication of major burns and leading cause of death in pts w/ an inhalation injury
When sepsis is suspected
cultures are immediately obtained from all possible sources, including the burn wound, blood, urine, sputum, oropharynx and perineal regions, and IV site Tx immediately begins w/ antibiotics when the C&S results are known, the antibiotic in use may be continued or changed based on results condition is critical and close monitoring of VS and mental status is needed
Acute Phase Nutritional Support
dietitian calculates caloric needs meeting daily caloric requirements is crucial high-protein, high-carb foods monitor lab values antioxidant protocol - selenium, acetylcysteine, ascorbic acid, vit E, zinc, and a multivitamin wt loss should no be more than 10% of preburn wt. weigh pt weekly
acute phase signs
diuresis from fluid mobilization occurs, and pt is less edematous bowel sounds return healing begins as WBCs surround burn wound and phagocytosis occurs necrotic tissue begins to slough granulation tissue forms partial-thickness burn wounds heal from edges and from dermal bed full-thickness burns must have eschar removed and skin grafts applied
In caring for a pt w/ burns to the back, the nurse knows that the pt is moving out of the emergent phase of burn injury when what is observed? serum sodium and potassium increase serum sodium and potassium decrease edema and ABGs improve diuresis occurs and Hct decreases
diuresis occurs and Hct decreases In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs so potassium levels decrease at the end of the emergent phase when fluid levels normalize.
Apligraf
donated neonatal foreskin fibroblasts and keratinocytes in bovine collagen gel permanent
OrCel
donated neonatal foreskin fibroblasts and keratinocytes in bovine collagen sponge permanent
rehab phase teaching plan
dressing changes s/s infection pain mgmt emotional support ROM exercises
electrical burns pt @ risk for
dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria - which can lead to acute renal tubular necrosis (ATN) delayed dysrhythmias or arrest can also occur w/out warning during the first 24 hrs after injury
To maintain a positive nitrogen balance in a major burn, the pt must: eat a high-protein, high-carb diet increase normal caloric intake by about 3X eat @ least 1500 cal/day in small frequent meals eat a gluten-free diet for the chemical effect on nitrogen balance
eat a high-protein, high-carb diet
phases of burn managment
emergent - resuscitative acute - wound healing rehabilitative - restorative
rehab phase nsg/interprofessional mgmt
encourage both pt and caregiver to participate in care use water-based creams the role of exercise cannot be overemphazied constant encouragement and reassurance - rehab may be need to be a primary focus for at least 6-12 mos
acute phase excision and grafting
eschar is removed down to subQ tissue or fascia graft is placed on clean, viable tissue wound is covered w/ autograft donor skin is taken w/ a dermatone choice of dressing varies grafts are attached w/ - fibrin sealant - sutures or staples - negative pressure wound therapy with early excision, function is restored, scar tissue minimized
3rd degree burn
extends through the dermis and into adipose full-thickness - leathery appearance, have no blisters and will have only minor, localized sensation b/c nerve endings have been destroyed
emergent phase nsg/interprofessional mgmt wound care - debridement
extensive surgical debridement is done in the OR - necrotic skin is removed releasing escharotomies and fasciotomies are done in the emergent phase, usually in burn centers by burn physicians pts find the first wound care to be both physicially and mentally demanding. provide emotional support
blisters
filled w/ fluid and protein are common in partial-thickness burns formed as a result of the inflammatory changes in the early burn injury physiological response that ↑ capillary permeability to allow for edema formation between the epidermis and the dermis contain many growth factors, and therefore may be responsible for the neovascularization of burn wound healing
emergent phase nsg/interprofessional mgmt nutritional therapy
fluid replacement takes priority over nutritional needs early and aggressive nutritional support w/in hrs of burn injury - ↓ complications/mortality - optimizes burn wound healing - minimizes negative effects
postburn reconstructive surgery
frequently required following a major burn the need for or possibility of further surgery will be reviewed @ the outpatient burn clinic appts after discharge
cold thermal injury
frostbite
acute phase PT and OT
good time for exercise is during and after wound cleaning passive and active ROM on all joints splints should be custom-fitted neck burns should sleep w/out pillows or w/ head hanging slightly over the top of the mattress to encourage hyperextension
emergent phase nsg/interprofessional care drug therapy
haldol - antipsychotic - sedative properties - neuropathic (nerve) pain analgesics/sedatives: - morphine - hydromorphone (dilaudid) - haloperdiol - lorazepam (Ativan) - Midazolam ongoing pain assessmant non-pharm techniques
any pt w/ preexisting heart, lung, or kidney disease
has poorer prognosis for recovery b/c of the increased demands placed on the body by a burn injury
The nurse is caring for a pt w/ partial- and full-thickness burns to 65% of the body. when planning nutritional interventions for this pt, what dietary choices should the nurse implement? full liquids only whatever the pt requests high-protein and low-sodium foods high-calorie and high-protein food
high-calorie and high-protein food A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
Acute Phase - Lab Values - Potassium: hyper
hyperkalemia may occur if the pt has: - renal failure - massive deep muscle injury - large amount of K is released from damaged cells hyperkalemia can cause: - heart dysrhythmias & vent failure - ECG changes tall tented T waves
emergent phase nsg/interprofessional mgmt nutritional therapy hypermetabolic state
hypermetabolic state proportional to the size of the wound occurs after a major burn injury resting metabolic expenditure may be ↑ by 50%-100% above normal core temp is ↑ - catecholamines, which stimulate catabolism and heat production, are ↑. massive catabolism can occur and in characterized by protein breakdown and increased gluconeogenesis caloric needs are about 5000 kcal/day supplemental vit and iron may be given
manifestations for Na
hypo - weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, confusion hyper - thirst, dried/furry tongue, lethargy, confusion, possibly seizures
Acute Phase - Lab Values - Potassium: hypo
hypokalemia occurs w/: - vomiting, diarrhea - prolonged GI suction - lengthy IV therapy w/out K hypokalemia can cause dysrhythmias s/s of hypokalemia: - fatigue, muscle weakness, leg cramps, heart dysrhythmias, paresthesias, and decreased reflexes
acute phase lab values - Sodium
hyponatremia - water intoxication - avoid w/ juices, nutritional supplements hypernatremia - hypertonic fluid replacement - improper tube feedings restrict Na in IVs, oral feedings
organic compounds
including phenols and petroleum products (creosote and gasoline) produce contact burns and systemic toxicity
emergent phase nsg/interprofessional mgmt wound care
infection is most serious threat to further tissue injury source of infection in burn wounds is likely the pt's own flora, mostly from the skin, resp, and GI tracts preventing cross-contamination from one pt to another is a priority for all member of the health care team
An older adult pt is moving into an independent living facility. What teaching will prevent this pt from being accidentally burned in the new home? cook for her stop her from smoking install tap water anti-scald devices be sure she uses an open space heater
install tap water anti-scald devices Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.
4th degree burn
involves muscle, tendon, and bone full-thickness - leathery appearance, have no blisters and will have only minor, localized sensation b/c nerve endings have been destroyed
2nd degree burn
involves the dermis of the skin, which contains the connective tissues, vessels, and nerves deep partial thickness partial-thickness wounds are pink to cherry red and wet and shiny w/ serous exudate. These wounds may or may not have intact blisters and are very painful when touched
emergent phase nsg/interprofessional mgmt drug therapy - VTE prophylaxis & tetanus
low-molecular-weight heparin or low-dose unfractionated heparin is started those w/ high bleeding risk, VTE prophylaxis w/ sequential compression devices, or compression stockings is recommended tetanus immunization is given routinely to all burn pts
A pt w/ type 2 DM is in the acute phase of burn care w/ electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this pt? replace the blood loss maintain a neutral pH maintain fluid balance replace serum potassium
maintain fluid balance This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.
emotional needs of pt and caregivers
many emotional and psychologica needs assess circumstances of burn injury burn survivors often experience anxiety, guilt, and depression new fears arise during recovery
burned legs
may first be wrapped w/ elastic (tensor/ACE) bandages to assist w/ circulation to leg graft and donor sites before ambulation once skin is completely healed and less fragile, custom-fitted pressure garments replace the elastic bandages
burns to face and neck and circumferential burns to the chest/back
may interfere w/ breathing as a result of mechanical obstruction secondary to edema or leathery, devitalized burn tissue (Eschar) may also signal possibility of smoke of inhalation injury
shivering
may occur as a result of chilling that is caused by heat loss, anxiety, or pain thermoregulation
rule of nines
method used to calculate the amount of fluid lost as the result of a burn; divides the body into 11 areas, each accounting for 9% of the total body area
contact w/ electric current can cause . . .
muscle contractions strong enough to fracture the long bones and vertebrae another reason to suspect long bone or spinal fractures is a fall resulting from the electrical injury use cervical spine immobilization during transport and subsequent diagnostic testing until injury is ruled out
emergent phase nsg/interprofessional mgmt perineum
must be kept as clean and dry as possible indwelling catheter - provides hourly urine outputs, an indwelling catheter prevents urine contamination of the perineal area perineal care - once-to-twice daily perineal and catheter care in the presence or absence of a perineal burn wound is essential assess the need for an indwelling urinary catheter on a daily basis and remove when no longer needed to limit risk of UTI If pt has frequent, loose stools, consider using a fecal diversion device
emergent phase nsg/interprofessional mgmt nutritional therapy cont'd
nonintubated pts w/ a burn <20% TBSA burn usuall able to eat enough to meet their nutritional needs intubated pts and/or those w/ larger burns require additional support enteral feedings have almost entirely replaced the need for parenteral feeding. Early enteral feeding, usuall w/ the use of smaller-bore tubes, preserves GI function, ↑ intestinal blood flow, and promotes optimal conditions for would healing
A pt has a 25% TBSA burn from a car fire. His wounds have been debrided and covered w/ a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: reapply a new dressing w/out disturbing the wound bed observe the wound for signs of infections during dressing changes apply cool compresses for pain relief in between dressing changes wash the wound aggressively w/ soap and water three times a day
observe the wound for signs of infections during dressing changes
acute phase complication - GI
paralytic ileus may be caused by sepsis diarrhea - from enteral feedings or antibiotics constipation - side effect of opioids, ↓ mobility, and low-fiber diet Curling's ulcer - diffuse superficial lesions - caused by a generalized stress response d/t ↓ blood flow to the GI tract H2 blockers, PPI closely monitor stool for bleeding
emergent phase nsg/interprofessional mgmt facial care
performed by open method the face is highly vascular and is subject to a great amt of edema. It is often covered w/ ointments and gauze but is not wrapped, to limit pressure on delicate facial structures
emergent phase nsg/interprofessional mgmt routine lab tests
performed to monitor fluid/electrolyte balance ABGs are drawn to assess adequacy of ventilation and oxygenation in pts w/ suspected or confirmed inhalation or electrical injury
emergent phase nsg/interprofessional mgmt neck
pillows are removed and a rolled towel is placed under the shoulders to hyperextend the neck and prevent neck contraction
xenograft (heterograft)
porcine skin temp - 3 days to 2 wks
Acute Phase - wound care - goals
prevent infection by cleansing & debriding necrotic tissue to lower bacterial growth promote wound re-epithelialization and/or successful skin grafting
Infection prevention
private room PPE sterile gloves w/ wound care handwashing after the dressing change is completed, the equipment and immediate environment are thoroughly cleaned and disinfected. The use of plastic liners on equipment is helpful in reducing potential contamination of equipment and facilitates cleaning
altered mental status
pt may be quite alert and able to provide answers to questions shortly after admission or until they are intubated pts are often frightened and need your calm reassurances and simple explanations of what to expect as you provide care unconsciousness or altered mental status in a burn pt usually results from hypoxia assoc w/ smoke inhalation other possibilities include head trauma, hx of substance abuse, or excessive amounts of sedation or pain medicaiton
paralytic ilues
pt w/ a larger burn may develop a paralytic ileus, w/ absent or ↓ bowel sounds curlings ulcer
emergent phase nsg/interprofessional mgmt nutritional therapy cont'd
pt w/ large (>20% TBSA) burns can develp paralytic ileus w/in a few hrs as a result of the body's response to major trauma in general, feedings can begin slowly @ 20-4- mL/hr and can be ↑ to the goal rate w/in 24-48 hrs if a large nasogastric tube is used, gastric residuals should be check frequently to rule out delayed gastric emptying bowel sounds should be assessed Q8H
autograft
pt's own skin permanent
cultured epithelial autograft (CEA)
pt's own skin cell cultures permanent
The pt received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this pt? sit or lie in the position of comfort wear a pressure garment for 8 hrs/day refer the pt to a counselor for psychosocial support use the sun to increase the skin color on the healed areas
refer the pt to a counselor for psychosocial support In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the patient looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.
acute phase nonpharmacologic strategies for pain mgmt
relaxation visualization, guided imagery hypnosis biofeedback music therapy
What is an important step in the initial treatment of a chemical injury?
remove clothes and jewelry don't assume decontamination occurred in the field - decontaminate @ hospital gently brush dry chemical from skin. Soap/water, don't scrub chemical should be removed quickly from the skin clothing containing chemical should be removed
chemical burns
result of contact w/ acids, alkalis, and organic compounds may affect skin, eyes, respiratory system, liver, and kidney
emergent phase
resuscitative time required to resolve immediate problems resulting from injury up to 72 hours primary concerns: - hypovolemic shock - edema ends when fluid mobilization and diuresis begin
A pt is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurse should take when meeting w/ the pt would be to: arrange a return-to-clinic appt and prescription for pain medications teach the pt and the caregiver proper wound care to be performed at home review the pt's current health care status and readiness for discharge to home give the pt written information and websites for information for burn survivors
review the pt's current health care status and readiness for discharge to home
biobrane
semipermeable silicone membrane bonded to nylon fabric temp - 10-21 days
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include: adherence of albumin to vascular walls movement of potassium into the vascular space sequestering the sodium and water in interstitial fluid hemolysis of RBCs from large volums of rapidly administered fluid
sequestering the sodium and water in interstitial fluid
classification of burn injury
severity is deteremined by depth of burn extent of burn calculated in % of total body surface area (TBSA) location of burn pt risk factors (age, past medical hx)
emergent phase nsg/interprofessional mgmt hands/arms
should be extended and elevated on pillows or foam wedges
A pt is admitted to the ED w/ first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury? SATA singed nasal hair generalized pallor painful swallowing burns on the upper extremities history of being involved in a large fire
singed nasal hair generalized pallor painful swallowing history of being involved in a large fire Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.
Chemical burns result in injuries to. . .
skin eyes respiratory system liver/kidney tissue destruction may continue up to 72 hours after chemical injury
rehab phase complications
skin and joint contracture - most common complications during rehab phase - develops as a result of shortening of scar tissue in the flexor tissues of a joint - positioning, splinting, and exercise should be used to minimize contracture
The injury that is least likely to result in a full-thickness burn is: sunburn scald injury chemical burn electrical injury
sunburn
1st degree burn
superficial partial thickness epidermis sunburn
A pt w/ a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? tachycardia restlessness hypokalemia GI distress
tachycardia
water intoxication
the burn pt may also develop a dilutional hyponatremia called water intoxication from excess water intake to avoid this condition, offer the pt fluids other than water, such as juice, soft drinks, or nutritional supplements to drink
burns to the hand and feet are challenging
to manage b/c of superficial vascular and nerve supply systems that need to be protected while the burn wounds are healing
emergent phase nsg/interprofessional mgmt drug therapy - antimicrobial agents
topical - silver sulfadiazine, mafenide acetate systemic agents are not usually used in controlling burn flora - initiated when diagnosis of invasive burn wound sepsis is made sepsis remains a leading cause of death in the pt w/ major burns, which may lead to multiple organ dysfunction syndrome
emergent phase nsg/interprofessional mgmt nutritional therapy - neg effects
ulcers GI bleeding malnutrition
WBC count
usually between 10,000-20,000 functional defects in WBCs are noted, and the pt is immunocompromised for a period after the burn injury
acute phase complications - infection
watch for s/s - hypo/hyperthermia - ↑ HR and RR - ↓ BP - ↓ urine output - mild confusion - chills - malaise - loss of appetite
rehab phase goals
work toward resuming functional role in society rehabilitate from any functional and cosmetic postburn reconstructive surgery that might be necessary
acute phase complications - endocrine
↑ blood glucose levels ↑ insulin production hyperglycemia effectiveness of insulin is ↓ b/c of relative insulin insensitivity leading to an ↑ blood glucose level as the pt's metabolic demands are met and less stress is placed on the entire system, this stress-induced condition is reversed
acute phase complications - Musculoskeletal
↓ ROM contractures
emergent phase complications - urinary
↓ blood flow to kidneys causes renal ischemia acute kidney injury acute tubular necrosis - myoglobin (muscle breakdown) - hemoglobin (RBC breakdown) adequate fluid replacement can counteract obstruction of the tubules
