BSCC BURNS IGGY

When does the acute phase of a burn injury begin and end?

Begins at about 36 to 48 hrs after injury and lasts until the wound closure is complete.

This type of wound dressing is often used for temporary wound coverage and closure composed of skin or membranes obtained from human tissue donors (homograft of allograft) or animals (heterograft or xenograft)

Biological dressing. These dressings are used in healing partial-thickness and granulating full-thickness wounds that are clean and free of eschar.

Biobrane is an example of this type of wound dressing.

Biosynthetic. Used for superficial-partial thickness burns such as scalds as a covering for meshed autografts/donor site dressing, it is made up of a nylon fabric that is partially embedded into a silicone film. Collagen is incorporated into both the silicone and nylon components. The nylon fabric comes into contact with the wound surface and adheres to it until epithelialization has occurred. the porous silicone film allows exudate to pass through.

List interventions for the nursing diagnosis: Ineffective tissue perfusion related to compression and impaired vascular circulation in extremities with circumferential burns.

--Assess peripheral pulses and perfusion every hour for 72 hrs; notify physician of changes in the pulses, capillary refill, color, temperature, or pain sensation --Elevate upper extremities with IV poles or on pillows; elevate lower extremities on pillows

List interventions for the nursing diagnosis: Risk for infection related to loss of skin, impaired immune response, and invasive therapies.

--Assess temperature, VS, and characteristics of urine and sputum every 1-4 hrs; monitor WBC, platelets, burn wound healing, and invasive catheter sites --Use appropriate protective isolation; provide meticulous wound care and antimicrobial agents as ordered. Sheave hair (except for eyebrows) 1 inch around the burn wounds; adhere to CDC guidelines for invasive catheter care; instruct visitors in burn unit guidelines --Obtain wound, sputum, urine and blood cultures as ordered

List interventions for the nursing diagnosis: Acute pain related to burns.

--Assess type, location, quality, and severity of pain --Monitor physiological responses to pain (elevated BP and HR, restlessness, and nonverbal cues. Use validated tools to assess pain and anxiety --Allay fear and anxiety --Administer analgesics and/or anxiolytic medication as ordered; administer IV during critical care phases --Asses response to analgesics or other interventions --Medicate patient before bathing, dressing changes, and major procedures as needed --Minimize open exposure to wounds --Use non-pharmalogical pain-reducing methods (distraction, relaxation techniques) as appropriate

What are some advantages of negative pressure wound therapy (NPWT)?

--Decompreses edematous interstitial spaces and increases local perfusion --Help draw wound edges closed uniformly --Removes wound fluid --Provides a closed, moist wound healing environment --Allows collection and quantification of wound drainage --Lower wound bacterial counts --Earlier reepithelialization --Prevents burn depth progression --Reduction in graft lass due to reduced edema and preservation of blood flow

How are tar and asphalt burns treated?

--Immediate removal of saturated clothing and cooling of water if available --No attempt is made to remove adherent tar at the scene because increased tissue damage and bleeding may occur

What some best practices for fluid resuscitation of the burn patient?

--Initiate and maintain at least one large-bore IV in an area of intact skin --coordinate with physicians to determine the appropriate fluid type and total volume to be infused during the first 24 hrs post burn --Administer one half of the total 24-hr prescribed volume within the first 8hrs postburn and the remaining volume over the next 16 hrs --assess IV access site, infusion rate, and infused volume at least hourly --monitor VS at least hourly --assess urine output at least hourly --assess for fluid overload (formation of dependent edema, engorged neck veins, rapid, thready pulse, lung crackles) --Measure additional body fluid output hourly

A burn patient (especially in circumferential burn of the extremities) are likely to develop compartment syndrome when tissue pressure in the fascial compartments of extremities increases, compressing and occluding blood vessels and nerves. What are the signs and symptoms of compartment syndrome?

--Intense pain --Paresthesia --Paralysis --Sustained intraabdominal pressure (IAP) greater than 20 mm Hg, with or without abdominal perfusion pressure (AAP=MAP-IAP) less than 60 mm Hg, and associated new organ system dysfunction or failure

Why is Lacted Ringer's the IV solution of choice for a burn patient?

--It is a crystalloid that has an osmolality and electrolyte composition most similar to normal body physiological fluids, and it does not contain glucose, which can cause a misleading high urine output from glycosuria and osmotic diuresis. In addition, LR contains lactate, which help to buffer the metabolic acidosis associated with hypoperfusion and burn shock. Because LR is a crystalloid, it does not provide any intravascular protein replacement it increase intravascular oncotic pressure. In the presence of increased capillary membrane permeability, the intravascular retention of LR is only about 25% of the infused volume, necessitating large fluid volume infusions to maintain circulating blood volume.

List interventions for the nursing diagnosis: Ineffective Airway Clearance and Impaired Gas Exchange related to tracheal edema and interstitial edema secondary to inhalation injury/and or circumferential torso eschar manifested by hypoemia and hypercarbia.

--Monitor O2 every hr, ABG and COHgb prn; chest x-ray study as ordered --Assess respiratory rate, character, and depth every hour; breath sounds 4 hours; LOC every hr; if not intubated, assess stridor, hoarseness, and wheezing every hour --Administer 100% humidified oxygen as ordered by non-rebreathing face mask or endotracheal tube --Evaluate the need for chest escharotomy during fluid resuscitation --Assist patient in coughing and deep breathing every hr while awake, suction as needed; monitor sputum characteristics and amount --Turn every 2 hrs to mobilize secretions; out of bed as tolerated --Elevate head of bed --Schedule activities to avoid fatigue

List interventions for the nursing diagnosis: Deficient fluid volume secondary to fluid shifts into the interstitium and evaporative loss of fluids from the injured skin.

--Monitor VS and urine output every hr until stable; mental status every hr for at least 48 hrs --Titrate calculated fluid requirements in first 48 hrs to maintain urinary output and hemodynamic stability --Record daily weight and hourly intake/output measurements; evaluate trends --Monitor serum electrolytes, Hct, Hgb, serum glucose, BUN, serum creatine levels at least twice daily for the first 48 hrs and then as required by patient status.

List interventions for the nursing diagnosis: Risk for hypothermia related to loss of skin and/or external cooling.

--Monitor and document rectal/core temperature every 1-2 hrs; assess for shivering --Minimize skin exposure; maintain environmental temperatures --For temperature <37 degrees C (98.6 degrees F), institute warming procedures

List interventions for the nursing diagnosis: Risk for ineffective individual coping and disabled family coping related to acute stress or critical injury and potential life-threatening crisis.

--Orient patient and family to unit guidelines and support services; provide written information and reinforce frequently; involve in plan of care; support adaptive and functional coping mechanisms --Implement interventions to reduce fatigue and pain --Consult social worker for assistance in discharge planning and psychological assessment issues; consult psychiatric services for inadequate coping skills or substance abuse treatment; promote use of group support systems

what are some psychological problems that the burn patient develop?

--PTSD --sexual dysfunction --severe depression

List interventions for the nursing diagnosis: Impaired physical mobility and self-care deficit related to burn injury, therapeutic splinting, and immobilization requirements after skin graft, and/or contractures.

--Perform active and passive ROM exercises to extremities every 2 hrs while awake. Increase activity as tolerated. Reinforce importance of maintaining proper joint alignment with splints and antideformity positioning --Elevate extremities --Provide pain relief measures before self-care activities and OT/PT --Explain procedures, interventions, and tests in clear, simple, age-appropriate language --Promote use of adaptive devices as needed to assist in self-care and mobility

List interventions for the nursing diagnosis: Risk for injury: gastrointestinal bleeding related to stress response and Imbalance Nutrition: less than body requirements related to ileus and increased metabolic demands secondary to physiological stress and wound healing.

--Place NG tube for gastric compression in >20% TBSA burns --Assess abdomen and bowel sounds every 8 hrs --Assess NG aspirate (color, quantity, pH, and guaiac); monitor stool for guaiac --Administer stress ulcer prophylaxis --Consult dietician. Initiate enteral feeding and evaluate tolerance; provide high-calorie/protein supplements prn; record all oral intake and count calories --Schedule interventions and activities to avoid interrupting feeding times --Monitor weight daily or biweekly

What findings may suggest a burn injury is the result of abuse or neglect? What should be done if abuse or neglect is suspected?

--Presence of other injuries --Wound characteristics (clear demarcartion and/or symmetrical wound pattern All potential or suspected abuse cases must be reported to the appropriate authorities as governed by state laws. The patient is hospitalized until social workers and protective services have investigated the patient's home environment to determine whether the patient will be safe on discharge.

List the functions of the integumentary system/skin.

--Protective barrier against infection and injury --Heat and fluid regulation --Synthesis of Vitamin D --Sensory contact with the environment --Determination of identity and presentable cosmetic appearance

What are some systemic signs of infection?

--altered LOC --changes in vital signs (tachycardia, tachypnea, temperature instability, hypotension) --increased fluid requirements for maintenance of normal urine output --hemodynamic instability --oliguria --GI dysfunction (diarrhea, vomiting, abdominal distension, paralytic ileus) --hyperglycemia --thrombocytopenia --changes in total WBC (above or below normal) --metabolic acidosis --hypoxemia

What are priority interventions for for the nonsurgical management of wounds?

--assess the wound --provide wound care --prevent infection and other complications

What are some local signs of infection?

--conversion of a partial-thickness injury to a full-thickness injury --ulceration of healthy skin around the burn site --erythematous, nodular lesions in uninvolved skin and vesicular lesions in healed skin --edema of healthy skin surrounding the burn wound --excessive burn wound drainage --pale, boggy, dry, or crusted granulation tissue --sloughing of grafts --wound breakdown after closure --odor

What are the uses of biologic dressings?

--debridement of untidy wounds after separation of eschar --promotion of re-epithelialization of deep partial-thickness wounds --temporary coverage after excision of the burn wound --protection of granulation tissue between autografts --test graft before autografting

signs and symptoms of fungal sepsis?

--delayed onset --mild disorientation --occasional diarrhea --fever --late hypotension --neutrophilia --low platelets

What are the advantages of biologic dressings?

--early adherence to the wound --reduction of evaporative heat and water loss --prevention of dehydration of granulation tissue --reduction of exudate protein losses --reduction of pain --assistance in wound debridement --enhancement of healing with partial-thickness injuries --protection of exposed neovascular tissue --inhibition of bacterial proliferation

What are some disadvantages of biological dressings?

--early lysis resulting in bacterial proliferation --expensive --rejection responses --not readily available --storage (some require refrigeration or freezing) --possible transmission of diseases, such as hepatitis

What are some needs to be addressed before discharge of the patient with burns?

--early patient assessment --financial assessment --evaluation of family resources --weekly discharge planning meeting --psychological referral --patient and family teaching (home care) --designation of principal learners (specify who will care for the patient) --development of teaching plan --training for wound care --rehab referral --home assessment (onsite) --medical equipment --public health nursing referral --evaluation of community resources --visit to referral agency --re-entry programs for school and work --long-term care placement --environmental interventions --auditory testing --speech therapy --prosthetic rehab

What are some special considerations for collangenase (Santyl) with Polysporin powder?

--expensive --apply once a day --use on partial-thickness wound with eschar --monitor for infection --may be used with barrier dressing such as Xeroform

What are some special considerations for PolyMem?

--expensive --contains no microbial properties --change earlier than 7 days if exudate is visible through the outer dressing --watch for signs of infection --use on partial-thickness wounds --must be covered with a secondary dressing --may be used on donor sites

What are some special considerations for Mepilex Ag?

--expensive --do not use on patients with known sensitivity to silver --do not use together with oxidizing agents such as hydrogen peroxide --may be used in partial and full- thickness burns --must apply a secondary dressing --may be used with skin grafts and donor sites

What are some special considerations for Aquacel Ag?

--expensive --may interfere with movement when used over joints --use on partial thickness wounds --must be covered with secondary dressing --do not use for patients who are sensitive or have allergic reaction to dressing or its components --do not use with oil based products

What are some ways to provide a safe environment for the burn patient and reduce the spread of infection?

--hand washing --no raw fruits or vegetables --no plants (they are known to carry Pseudomonas) --isolation techniques --no shraing of equipment between patients/disinfecting equipment --ill people and small children should be restricted --early detection of infection

List the physiological effects of carbon monoxide poisoning at a carbon monoxide level between 11-20% (mild poisoning)?

--headache --decreased cerebral function --decreased visual acuity --slight breathlessness

What are some nonpharmacological interventions to reduce pain in the patient with a severe burn?

--hypnosis --guided imagery --therapeutic touch --massage of non burned areas --sleep promotion --a quiet environment --tactile stimulation --prevent shivering --reposition every 2 hrs

What are the benefits of ambulation for the burn patent?

--inhibits bone density loss --strengthens muscles --stimulates immune function --promotes ventilation

Signs and symptoms of gram-positve sepsis?

--insidious onset (2-6 days) --severe disorientation and lethargy --severe ileus --rare diarrhea --fever --late hypotension --neutrophilia --normal platelets

What are some special considerations for nitrofurazone (Furacin)?

--may cause contact dermatitis (rare) --messy to apply in cream form --may cause renal problems if used in extensive burns --observe for signs of allergic reaction and evidence of superinfection

What are some special considerations for silver sulfadiazine (Silvadene, Thermazene)?

--may cause pruritis, burning, and leukopenia --not effective against Pseudomonas --watch for signs of infection such as soupiness of wound area --watch for allergic reaction causing a drop in WBC --do not use if reaction to sulfonamide has occurred

What are some special considerations for Polymyxin B-bacitracin (AK-Poly-Bac, Polysporin)?

--may cause urticaria, burning, and inflammation --does not penetrate eschar --apply every 2-8 hrs to keep areas moist

What are some special considerations for gentamicin sulfate (Gramycin, Gentamar)?

--may have ototoxic and nephrotoxic effects (check creatine) --may result in resistance to certain organisms --use with caution in patients with decreased kidney function --monitor serum and urine creatine clearance before and during treatment

What are some special considerations for mafenide acetate (Sulfamylon)?

--may lead to infection --may cause metabolic acidosis, hyperpnea, and rash --when applied may cause pain that lasts 30-40 mins --premedicate for pain before application --monitor blood gas and serum electrolyte levels --monitor for infection

What are some special considerations for Aricoat?

--needs to be wet down with sterile water --expensive --may cause elevated serum silver levels, elevated liver function tests, and transient gray facial discoloration --do not use with oil-based products or other topical antimicrobials --contraindicated in patients with known hypersensitivity to any components of the product --may dry out and adhere to the wound surface; soak off to remove

What positions prevent head and neck contractures?

--no pillow --place a towel under the patient's neck or shoulder --neck splint

What positions prevent hip contractures?

--place patient supine with the lower extremity extended --use trochanter roll --use foam wedge along the lateral aspect of the thigh

What positions prevent upper chest and chest contractures?

--place the patient in the supine position --place a folded towel under the spine, between the scapulae

List the benefits of pressure dressings.

--prevents venous stasis and edema --prevent contractures and tight hypertrophic scars For best effectiveness pressure dressings are worn at least 23 hrs a day, everyday until the scar tissue is mature.

Signs and symptoms of gram-negative sepsis?

--rapid onset (12-36 hr) --mild disorientation --severe ileus --severe diarrhea --hypothermia --early hypotension --neutropenia --low platelets

What positions prevent axilla contractures?

--support the abducted arm with suspension from IV pole or bedside table. --axilla splint

List the benefits of nanoemulsions.

--when applied to a wound, both the active antimicrobial ingredients and the high energy release destabalize the microbe membrane, resulting in pathogen cell death. --they are selectively toxic to pathogens but not irritating to skin or mucous membranes. --in burns they attenuate the wound inflammatory response and infection.

What are some indications that the burn patient has a positive perception of his or her own appearance, body functions, and self worth?

--willingness to touch the affected part --adjustment to changes in body function --willingness to use strategies to enhance appearance and function --successful progression through the grieving process --use of support systems --active participation in self care activities

Lab value for Carboxyhemoglobin

0%-10% (elevated in the burn victim as a result of inhalation of smoke and carbon monoxide)

Describe the 3 classifications of inhalation injuries.

1. Exposure to gases (carbon monoxide or cyanide) causes tissue hypoxia 2. Supraglottis or injury above the glottis: may cause airwway obstruction 3. Subglottic or injury below the glottis: impaired ciliary activity, erythema, hypersecretion, edema, ulceration of the mucosa, increased blood flow, and spasm of bronchi/or bronchioles

A ___% or more weight loss is significant and requires the evaluation and modification of calorie intake.

10

Lab value for Urea Nitrogen

10-20 mg/dL (usually elevated in the burn victim due to fluid loss)

The skin can tolerate temperatures up to ______ degrees without injury.

104

Lab value for Hemoglobin

12-16 g/dL (women) 14-18 g/dL (men) (usually elevated in the burn victim due to fluid loss)

Lab value for Sodium

136-145 mEq/L (usually decreased in the burn victim since sodium is trapped in edema fluid and lost through plasma leakage)

A __% loss of body weight indicates a mild nutritional deficit.

2

Lab value for Albumin

3.5-5.0 g/dL (Low in the burn victim. Protein is lost through the wound and through vascular membranes because of increased permeability)

Lab value for Potassium

3.5-5.0 mEq/L (Elevated in the burn victim as a result of disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis)

Lab value for PaCO2

35-45 mm Hg (slightly increased in the burn victim due to respiratory injury)

Lab value for Hematocrit

37-47% (women) 42%-52% (men) (usually elevated in the burn victim due to fluid loss)

Nutritional requirements for a patient with a large burn are can exceed ________ kcal/day

5000. Patients also require a high protein intake.

Lab value for Total Protein

6.4-8.3 g/dL (Low in the burn victim. Protein exudate is lost through the wound)

Arterial oxygenation less than _____ mm Hg is an indication for intubation and mechanical ventilation.

60

Lab value for pH

7.35-7.45 (Low in the burn victim due to metabolic acidosis)

Lab value for Glucose

70-105 mg/dL (usually elevated in the burn victim as a result of the stress response and altered uptake across injured tissues)

Lab Value for PaO2

80-100 mm Hg (Slightly decreased in the burn victim)

Lab value for Chloride

98-106 mEq/L (Elevated in the burn victim as a result of fluid volume loss and reasorption of chloride in the urine)

Lab value for WBC

<2,000 and >100,000/microliter; transient decrease from use of topical silver sulfadiazine; increase with infection

Lab value for Platelets

<20,000/microliter; decrease in large TBSA, hypothermia-induced bleeding disorders, or infection

Lab value for Serum Lactate

>2.2 mEq/L; increase in metabolic acidosis, should decrease if fluid resuscitation is adequate

What metabolic changes occur as a result of a burn injury?

A serious burn injury greatly increases metabolism by increasing secretions of catecholamines, ADH, aldosterone, and cortisol.

This type of chemical agent is found in many household and industrial products, such as bathroom cleaners, rust removers, and acidifiers for home swimming pools. Depth of a burn injury is limited because the cause coagulation necrosis of tissue and precipitation of protein.

Acids. (Hydrofluoric acid causes extensive tissue damage. The fluoride ion is very toxic and is potentially lethal even with small exposures, because it causes hypocalcemia by rapidly binding to free calcium in the blood)

What are some causes of respiratory failure in the patient with burns?

Airway edema during fluid resuscitation, pulmonary capillary leak, chest burns that restrict chest movement, and carbon monoxide poisoning.

This type of chemical agent is commonly encountered in the home and industrial environment include oven cleaners, lye, wet cement, and fertilizers. It loosens tissues by protein denaturation and liquefaction necrosis, thereby allowing the chemical to diffuse more deeply into the tissue. It also binds to tissue proteins and makes it more difficult to stop the burning process.

Alkalies (also known as bases).

What is an indication of cyanide poisoning in a patient who does not have severe burns?

An elevated lactate level. Patients who do not respond to 100% oxygen should be treated with commercially available cyanide antidote kits.

This type of wound dressing is a substance with two layers: a Silastic epidermis and a porous dermis made from beef collagen and shark cartilage.

Artificial skin.

When is ambulation initiated for the burn patient?

As soon as possible after the fluid shifts have resolved 2-3 times a day and progresses in length each time.

How often are range of motion exercises performed on the burn patient?

At least 3 times a day.

This type of infection occurs from overgrowth of patient's own normal flora and invades other body areas.

Auto-contamination.

This type of graft is taken from the patient's own body.

Autograft.

What is the disintegration of of tissue by the action of the patient's own cellular enzymes?

Autolysis.

What is the most frequent cause of death at injury scene?

Carbon monoxide poisoning.

What is a priority concern in the patient that suffers a AC shock?

Cardiopulmonary arrest by ventricular fibrillation.

What is the role of increased secretion of catecholamines in the patient with severe burns?

Catecholamines activate the stress response. The increased production (and loss) of heat breaks down protein and fat, rapidly uses glucose and calories, and increases nitrogen loss.

Describe the closed technique for applying topical antibiotics.

Clean or aseptic technique is used to apply the agent directly to the burn wound and then the wound is dressed.

Describe the open technique for applying topical antibiotics.

Clean or aseptic technique is used to apply the agent directly to the burn wound without dressing the wound.

What bacterial infection are burn patients at risk for?

Clostridium tetani. Patients are given Tetanus shot for prophylaxis.

This type of burn occurs when hot metal, tar, or grease contacts the skin, often leading to a full-thickness injury.

Contact burn

How does a hypermetabolic condition affect body core temperature?

Core body temperature is increased. A central body temperature control change occurs to adapt to the hypermetabolic state, resulting in the development of a low-grade fever. This change is a "resetting" of the body's normal temperature-control system to a higher baseline body temperature.

This type of infection occurs when organisms from other people or environments are transferred to the patient.

Cross-contamination.

Parker (Baxter) Formula for burn fluid resuscitation

Crystalloid only (lactated Ringer's) 4 mL/kg% TBSA burn

Modified Parkland Formula for burn fluid resuscitation

Crystalloid only (lactated Ringer's) 4 mL/kg% TBSA burn + 15 mL/m2 of TBSA

This type of wound dressing can be grown from a small specimen of epidermal cells from an unburned area of the patient's body.

Cultured Skin.

Burns reduce activation of vitamin ___.

D. Partial-thickness burns reduce the activation of vitamin D, and this function is completely lost in full-thickness burns.

What two medications would a patient with pulmonary edema and any degree of heart failure?

Digoxin and diuretics

What precaution should the nurse take in administering diuretics to the patient with a severe burn injury?

Diuretics do not increase cardiac output; they actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis which increases the risk for hypovolemic shock. Cardiac output can be increased by adjusting the IV flow rate and amount. The patient with an electrical burn injury may benefit from the use of diuretics such as mannitol (Osmitrol)

What is a priority assessment for the patient with an electrical burn?

ECG tracings at the time of admission and continue ECG monitoring throughout the resuscitation phase.

What type of burns occurs when an electrical current enters the body?

Electrical burns

What causes tissue injury from an electrical burn?

Electrical energy being converted to heat energy.

Why is it important to a home water heater no higher than 120 degrees F?

Exposure to a temperature of 60 degrees C (140 degrees F) causes full-thickness tissue destruction (third-degree burns) in a little as 3-5 secs. Most hot water heaters are set to 140 degrees F. Children and the elderly are at greater risk of thermal injury at lower temperatures because of their thinner skin and their decreased agility in moving to avoid harm.

Using this technique, the surgeon cuts away the burn wound to the level of the superficial fascia.

Fascial technique.

What positions prevent posterior neck contractures?

Have the patient turn from side to side.

Elevated blood osmolarity, hematocrit, and hemoglobin are signs of ________________.

Hemoconcentration.

This type of graft is skin obtained from another species.

Heterograft/xenograft. Pigskin is the most common.

This type of graft is is human skin obtained from a cadaver and provided through a skin bank. They are fresh or frozen; frozen skin is thawed in a warm bath of sterile normal saline before application.

Homograft/allograft.

What is the best route for giving opioid drugs during the resuscitation post burn stage?

IV route because of problems with absorption from the muscle and the stomach. When given IM or subQ the drug components remain in the tissue spaces and do not relieve pain.

Why may larger doses of antibiotics need to be used in the patient with burns?

Increased metabolism of drugs.

Heart rate ___________ and cardiac output ________ because of interstitial fluid shifts and hypovolemia that occurs during a burn injury.

Increases; decreases.

What is the focus of interventions for the burn patient acute respiratory distress syndrome?

Increasing lung compliance and improving PaO2 levels. The priority nursing care actions are coordinating respiratory therapy strategies (PEEP and IMV) and monitoring the patient's response to these interventions.

This method determines kilocalories of energy expenditure by measuring oxygen consumption (Vo2) and carbon dioxide production (Vco2).

Indirect calorimetry. Measurements are taken while the patient is at rest--usually after the most recent dressing changes or other stressful procedures. It is usually performed upon admission and each week until burns are closed.

What is the leading cause of death in the acute phase of a burn injury?

Infection and burn wound sepsis. Handwashing and using aseptic technique in caring for wounds and during invasive monitoring reduces risk.

Name the two main compensatory responses to a burn injury.

Inflammatory response and sympathetic nervous system stress response.

These complex cases involve both thermal and chemical burns, and are highly associated with inhalation injuries and more extensive TBSA injury.

Injury from the manufacturing of meth in clandestine labs.

When does the rehabilitation phase of a burn injury begin and end?

It begins with wound closure and ends when the patient returns to his or her highest level of functioning. the emphasis is on the psychosocial adjustment of the patient, the prevention of scars and contractures, and the resumption of preburn activity, including work, family, and social roles.

Describe an amniotic membrane used for the treatment of a severe burn.

It is a large size, low cost highly available biological dressing that adheres to the wound. It requires dressing changes because it does not develop a blood supply and disintegrate in about 48 hrs.

Describe hypovolemic burn shock.

It is caused by massive loss of intravascuclar fluid from increased vessel membrane permeability and evaporative loses through the open wound beds

What positions prevent posterior shoulder contractures?

Keep the arm arm slightly behind the midline.

What positions prevent elbow contractures?

Keep the joint in the extended position.

What causes extensive edema (even in areas that were not burned) in a severe burn injury?

Leakage of fluid and electrolytes from the vascular space.

What is the difference between a low voltage burn and high voltage electrical injury?

Low voltage=1000 V or less High=more than 1000 V

What positions prevent anterior shoulder contractures?

Maintain the arm upper arm at 90 degrees of abduction from the lateral aspect of the trunk.

When can reconstructive and cosmetic surgery be performed on the patient with burns?

Many years after the injury. Patients often have unrealistic expectations about surgery so it is important to make sure patients and family receive adequate teaching.

Loss or bicarbonate in the urine causes _____________ in the patient withe a severe burn injury.

Metabolic acidosis.

Why is it important to remove clothes and jewelry on a burn patient?

Metal retains as heat can cause continuing burning and the tissue can swell around the clothes and jewelry. The patient is covered with a clean, dry sheet and blankets to prevent hypothermia and further contamination of wounds.

These type injuries are caused by contact with hot liquids or steam such as hot liquid spills or immersion scald injuries.

Moist heat (scald) injuries.

What type of analgesic is suitable for escharotomy?

No anesthesia is needed because nerve endings have been destroyed by the burn injury, but sedation and analgesics are given to reduce anxiety.

How should the nurse asses BP in the patient with a severe burn involving the upper extremities?

Noninvasive blood pressure readings are inaccurate in these patients and invasive blood pressure may be needed.

This type of chemical agent is found in phenols and petroleum compounds (e.g., gasoline, kerosine, chemical disinfectants) and can produce cutaneous burns as well as be absorbed with resulting systemic effects.

Organic compounds. Phenols cause severe coagulation necrosis of dermal proteins and produce a layer of thick, nonviable tissue (eschar). Petroleum products such as gasoline promote cell membrane injury and dissolution of lipids with resulting skin necrosis. Systemic effects such as CNS depression, hypothermia, hypotension, pulmonary edema, and intravascular hemolysis may be severe or even fatal. Chemical pneumonitis and bronchitis may occur from inhalation of fumes. Other complications observed with petroleum product exposure include hepatic and renal failure and sudden death.

With ______________ burns nerve endings are exposed, increasing sensitivity and pain.

Partial-thickness

This type of wound involves the entire epidermis and varying depths of the dermis.

Partial-thickness burns

What positions prevent lateral trunk contractures?

Place the patient supine with the arm of the unaffected side up over the head.

What is the main risk of mechanical ventilation in the burn patient?

Pneumonia.

What would one suspect when a patient has a vague or inconsistent injury history, burns to the face and hands, and signs of agitation or withdrawal?

Potential meth-related injury.

Modified Brooke Formula for burn fluid resuscitation

Protenate of 5% albumin in 0.9% saline Lactated Ringer's without dextrose 0.5 mL to 1.5 mL/kg/% TBSA burn

What should the nurse do to help the patient tolerate deep endotracheal suctioning?

Provide analgesics--patients report the procedure is very painful.

How can the nurse promote ventilation in the patient with burn?

Removing eschar and loosening dressings that can reduce chest wall expansion.

How are flame burns extinguished?

Rolling the patient on the ground, smothering the flames with a blanket or other cover, dousing the flames with water. (Ice is never applied to the wound because further tissue damage may occur as a result of vasoconstriction and hypothermia.)

What may glycosuria in the absence of diabetes indicate?

Sepsis.

What is burn shock?

Shock from the intravascular volume loss created by the sudden fluid and solute shifts immediately after burn injury.

Why should the nurse monitor for in African American patient with a severe burn?

Sickle cell crisis. The injury can trigger crisis in patients who have the disease and in those who carry the trait.

Why is it important to assess and document a burn patient's respiratory status frequently?

So that ventilator changes can be made. Document and immediately report any signs of respiratory distress or change in respiratory pattern (change in ABGs and O2) to the burn team and respiratory therapist.

This type of wound dressing is comprised of multiple layers of gauze applied over the topical agents on the burn wound.

Standard wound dressing.They are applied distal to proximal and changed and reapplied every 8 to 24 hrs.

What are common causes of respiratory problems related to burns?

Superheated air, steam, toxic fumes, or smoke.

This type of dressing is made of a solid silicone and plastic membrane.

Synthetic dressings. They are applied directly to the surface of a clean or surgically prepared wound and remain in place until they fall off or are removed. Many of these dressings of these dressings are transparent or translucent, and the wound can be inspected without removing the dressing. Pain is reduced at the site because these agents also prevent contact of the wound's nerve endings with air.

Using this technique, the surgeon removes very thin layers of the necrotic burn surface until bleeding tissue is encountered. Bleeding indicates that a healthy bed of healthy dermis or subcutaneous fat has been reached.

Tangenital technique.

How is the upper respiratory airway affected by inhaled smoke or irritants?

The cause edema and obstruct the trachea.

What are priority areas for autograft skin application?

The face, the hands, the feet, and over joints

How can smoke and combustion products affect the lining of the trachea and bronchi?

The lining may slough off 48-72 hrs after injury, enter the airway, narrow the tracheal lumen, and obstruct the lower airways.

Why does a severe burn injury cause a decrease in blood volume and blood pressure?

The loss of plasma fluids and protein.

Circulatory overload from resuscitation therapy can cause fluid overload. What are some manifestations of fluid overload and what should the nurse do to intervene?

The patient is short of breath and has dyspnea in the supine position. Crackles are heard on auscultation. When pulmonary edema is present, elevate the head to 45 degrees, apply humidified oxygen, and notify the burn team or rapid response team.

What does the presence of tea-colored urine suggest?

The presence of hemochomogens (myoglobin) released as a result of severe deep tissue damage in a process called rhabdomyolysis

What immunologic changes result from a burn injury?

The protective layer of the skin is destroyed, increasing the risk for infection. The injury activates the inflammatory response and often suppresses all types of immune functions. Topical and systemic antibiotics, general anesthesia, blood transfusions, and the stress of surgery further reduce immune function.

What aspect of burn causes the patient to lose heat?

The skin barrier is destroyed.

Why do older adults have an increased risk of of greater burn severity, even at lower temperatures of shorter duration?

The skin is thinner in older adults.

How does a burn injury effect kidney function?

There is decreased blood flow to the kidneys and cellular debris (hemoglobin, myoglobin, uric acid, and potassium) and during the fluid shift, blood flow may not be adequate for glomerular filtration.

What are some special considerations when a patient is recieving paralytic drugs such as atracurium (Tracurium) or necuronium (Norcuron)?

These drugs remove all breathing control from the patient making mechanical ventilation easier. These drugs do not prevent the patient from seeing and hearing or from experiencing fear, pain, or loss of control. Any patient receiving a neuromuscular blockade drug must also receive drugs for sedation, analgesia, and anti-anxiety unless contraindicated. These patients need to be monitored frequently because they cannot call for help.

What should the nurse teach a burn patient about feelings of grief, loss, anxiety, anger, fear, and guilt?

These feelings are normal.

Why do children usually require relatively more resuscitation fluid?

They have a greater ratio of body surface area to mass than that of adults, and higher evaporative loss.

Why are small blisters left intact on a burn patient?

They provide a protective barrier that promotes wound healing. Large blisters are opened.

Describe distributive burn shock.

Third-spacing greatly expands the area in which total body fluid contained to include the intravacular space plus intracellular and interstitial spaces.

What is a priority nursing intervention for a patient who is wheezing sounds suddenly disappear?

This finding indicates impending airway obstruction and demands immediate intubation.

What can cause a deep partial-thickness wound progress to full-thickness?

Tissue damage increases with infection, hypoxia, or ischemia.

What is the most common and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion in the patient with burns less than 35%?

Urine output. Regardless of the total amount of fluid calculated as needed to meet the fluid requirements of the patient, the amount of fluid given depends on how much IV fluid per hour is needed to maintain the hourly urine output rate of 0.5 mL/kg (about 30 mL/hr).

What positions prevent leg contractures?

Use a small pillow between the legs

How are WBCs affected by a severe burn?

WBC first rises and then drops rapidly with a "left shift" as the immune system becomes unable to sustain its defenses. If sepsis occurs, the total WBC may be as low as 2000 cells/mm3.

When may it be necessary to administer a paralytic drug to a patient with severe burns?

When a patients activity during mechanical ventilation severely compromises respiratory mechanics.

This zone of thermal injury has the greatest area of tissue necrosis at the core of the wound and is the site of irreversible skin death and is similar to a full-thickness burn.

Zone of coagulation.

This zone of thermal injury is the outermost area of minimal cell injury and has early spontaneous recovery and is similar to a superficial burn.

Zone of hyperemia.

This zone of thermal injury is where vascular damage and reduced blood flow has occured.

Zone of stasis.

What are some musculoskeletal complications that can result from a burn injury?

immobility. Range of motion upon admission and throughout the treatment process prevents risk.

Why is autolysis rarely used in North America for larger burns?

it is slow and results in a prolonged hospital stay, increasing the risk of infection.

What cardiopulmonary complications is the burn patient at risk for?

pneumonia, infection, and sepsis.

What positions prevent ankle contractures?

use a padded footboard or splint with heels free of pressure

What positions prevent wrist and finger contractures?

use a splint

Describe the process of hydrotherapy for the burn patient.

wounds are debrided and cleaned one or two times a day during hydrotherapy. Hydrotherapy is usually performed by showering the patient on a specifically designed shower table or washing only small areas of the wound at the bedside. Showering enhances wound inspection and allows water temperature to be kept constant.

How can minor burns be prevented?

--Assess hot water before bathing (tank should be set at 140 degrees) --use pot holders --never add a combustible to an open flame --use sunscreen

What are strong indications that an inhalation injury may be present?

--Burns on the lips, inside the mouth, face, ears, neck, eyelids, eyebrows, and eyelashes --Black particles of carbon in the nose mouth, and sputum and edema of the nasal septum indicate smoke inhalation, as does a "smoky" smell to the patient's breath.

List general emergency management for all types of burns.

--assess airway for patency --administer oxygen as needed --cover the patient with a blanket --keep the patient NPO --elevate the extremities if no fractures are obvious --obtain vital signs --initiate an IV line and begin fluid replacement --administer tetanus toxoid for prophylaxis --perform head to toe assessment

List emergency management of electrical burns.

--at the scene, separate the patient from the electrical current

What are some indications that may mean a patient is about to lose his or her airway?

--becomes progressively hoarse --develop a brassy cough --drool or difficulty swallowing --produce sounds on exhalation that include audible wheezes, crowing, or stridor

List the physiological effects of carbon monoxide poisoning at a carbon monoxide level between 41-60% (severe poisoning)?

--coma --convulsions --cardiopulmonary instability

List the physiological effects of carbon monoxide poisoning at a carbon monoxide level between 21-40% (moderate poisoning)?

--headache --tinnitus --nausea --drowsiness --vertigo --altered mental state --confusion --stupor --irritability --decreased BP, increased and irregular HR, depressed ST segment on ECG and dysrhythmias --pale to reddish purple skin

List emergency management of chemical burns.

--if dry chemicals are present on skin or clothing, DO NOT WET THEM --brush off any dry chemicals present on the skin or clothing --remove the patient's clothing --ascertain the type of chemical causing the burn --If chemical is in or near the eyes, remove contact lenses, and irrigate eyes with saline or clean water (Tissue damage from a chemical burn continues until the chemical is completely removed or neutralized.) Medical personnel may need to wear PPE to prevent chemical injury

List the physiological effects of carbon monoxide poisoning at a carbon monoxide level between 1%-10% (normal)?

--increased threshold to visual stimuli --increased blood flow to vital organs

List priority immediate care interventions within the first hour of burn injury.

--maintain an open airway, ensuring and equate breathing and circulation --limit the extent of the injury --maintain function of vital organs

How can severe burns be prevented?

--never smoke in bed (avoid alcohol and drugs that induce sleep when smoking) --keep matches away from children --monitor space heaters --fireplace maintenance --do not smoke when oxygen is in use --use smoke and carbon monoxide detectors (one for each room) --develop fire evacuation plan (never rented a burning building to retrieve belongings)

List some manifestations of carbon monoxide poisoning.

--oxyhemoglobin disassociates to a left curve, which impairs oxygen unloading at the tissue level (Pao2 may be normal) --the vasodilating action if carbon monoxide causes a "cherry red" color (or at least the absence of cyanosis)

What intervention should the nurse anticipate if a patient's hematocrit is less than 20% to 25% and the patient has manifestations of hypoxia?

Blood transfusion

What causes fluid shift/third spacing?

Blood vessels near the burn start dilating and leaking fluid into the interstitial space.

What specific information is needed in regard to the health history of a burn victim?

Cardiac and kidney problems; chronic alcoholism, substance abuse, and diabetes mellitus since all these problems influence fluid resuscitation. Also, obtain a drug history that includes allergies, current drugs, and immunizations. Assess for other injuries.

These burns occur with flame, electrical, or chemical burns.

Deep full-thickness

This type of wound always need early excision and grafting. Grafting decreases pain and length of stay and hastens recovery. Amputation may be needed when an extremity is involved

Deep full-thickness wounds

This type of wound extends beyond the skin to the underlying fascia and tissue. Muscle, bone, and tendons are damaged and may be exposed. The wound is blacked and depressed, and sensation is completely absent.

Deep full-thickness wounds

This type of wound surface is red and dry with white areas in deeper parts (dry because fewer blood vessels are patent). When pressure is applied to the burn, it blanches slowly or not at all. Edema is moderate, and pain is lessened because more nerve endings have been destroyed.

Deep partial-thickness wounds

These type of heat injuries are caused by open flame such as house fires and explosions.

Dry heat injuries.

What type of gastrointestinal changes result from a burn injury?

Due to fluid shift and sympathetic nervous system stress response, the GI tract has decreased blood flow. Gastric mucosal integrity and motility are impaired. Peristalsis decreases, and paralytic ileus may develop. Secretions and gases collect in the intestines and stomach, causing abdominal distention. Curling ulcer may develop within 24 hrs due to decreased stomach mucous lining.

Why is eschar removal for full-thickness wounds difficult?

Eschar often sticks to the lower tissue layer of collagen fibers.

What type of surgical interventions may be needed for a circumferential burn injury?

Esharotomies (incisions through the eschar) or fasciotomies (incisions through eschar and fascia) relieve pressure and allow normal blood flow and breathing.

After a burn injury massive fluid loss occurs through ___________.

Evaporation

With ______________ burns nerve endings are completely destroyed. At first these wounds may not transmit sensations except at the wound edges when sharp stimulus is applied. Despite this destruction, patients have a full or pressure-type of pain in these areas.

Full-thickness

How do organic compounds cause damage to tissues?

The are fat soluble and are easily absorbed through the skin. If absorbed they have toxic effects on the kidneys and liver.

What happens during the process of fluid remobilization?

The capillary leak stops (usually within 24 hrs). The diuretic stage begins at about 48-72 hrs after the burn injury as capillary membrane integrity returns and edema fluid shifts from the interstitial spaces into the intravascular space. Blood volume increases, leading to increased kidney blood flow and diuresis unless kidney damage has occurred. Body weight returns to normal over the next few days as edema subsides.

What determines the amount fluid shifted in a burn injury?

The extent and severity of the burn.

What determines the severity of a burn injury?

The severity of burns is determined by how much of the body surface area is involved and the depth of the burn. The degree of tissue damage is related to the agent causing the burn and to the temperature of the heat source, as well as how long the skin is exposed to it. Differences in thickness in various parts of the body also affect burn depth.

Sodium is retained by the body as a result of the endocrine response to stress. Aldosterone secretion increases, leading to increased sodium reabsorption by the kidney. Why then are burn patients at risk for hyponatremia?

The sodium passes into the interstitial space of the burned areas with the fluid shift. Thus, despite the increased amount of sodium in the body, most of the sodium is trapped in the interstitial space and a sodium deficit occurs in the blood.

Why are electrical burns called the "grand masquerader" of burns?

The surface injuries may look small but the associated internal injuries can be huge.

Why is intubation often performed as an early intervention for a burn injury that involves the airway?

The tissues rehydrate and swell even in the resuscitation phase.

Where should the nurse auscultate when assessing airway injury in a burn victim?

The upper airway (trachea and mainstem bronchi). Auscultation of these areas may reveal wheezes which indicate partial obstruction.

What are the most common areas affected by a thermal (heat) injury?

The upper airway above the glottis (nasopharynx, oropharynx, and larynx)

How can gastrointestinal ulcers be prevented in the patient with a severe burn?

The use of H2 histamine blockers, proton pump inhibitors, drugs that protect GI tissues, and early enteral feeding.

What type of burn occurs when clothes ignite from heat or flames produced by electrical sparks to cause cell injury by coagulation?

Thermal burns

Name the 3 ways electrical burn injuries can occur.

Thermal burns, flash burns, and true electrical injury

How do irritants coming in contact withe the upper airway affect the vocal cords?

They cause a reflex closure of the vocal cords that reduces the entry of smoke and toxic gases into the lungs.

What effect do acids have on the skin?

They damage tissue by coagulating cells and skin proteins, which can limit the depth of tissue damage.

This term is a continuous leak of plasma from the vascular space into the interstitial space.

Third spacing or capillary leak syndrome

Depending on the extent of the burn injury, the patient's caloric needs _________ or ___________ normal energy needs.

Triple; double. These increased rates peak 4-12 days after the burn and remain elevated for months until all wounds are closed.

The type if burn occurs when direct contact is made with an electrical source.

True electrical injury

What causes hemoconcentration in a burn client?

Vascular dehydration.

Is the immediate vascular response to a burn injury vasodilation or vasoconstriction?

Vasoconstriction. Blood vessels to the burned skin are occluded and blood flow is reduced or stopped. Damaged macrophages within the tissues release chemicals that at first cause vasoconstriction.

List emergency management for radiation burns.

--remove the patient from the radiation source --if the patient has been exposed to radiation from an unsealed source, remove his or her clothing (using tongs or lead protective gloves) --if the patient has radioactive particles on the skin, send him or her to the nearest designated adoration decontamination center --help the patient bathe or shower

List 6 priorities for the management of the resuscitation phase if an injury.

--secure airway --support circulation by fluid replacement --keep the patient comfortable with analgesics --prevent infection by careful wound care --maintain body temperature --provide emotional support

List emergency management for flame burns.

--smother the flames --remove smoldering clothing and all metal objects

What are some age-related changes increasing complications from a burn injury?

--thinner skin, sensory impairment, decreased mobility --slower healing time --more likely to have cardiac impairments --reduced inflammatory and immune responses --reduced thoracic and pulmonary compliance --more likely to have preexisting medical conditions

Fluid shift, with excessive weight gain, occurs in the first _____ hrs after the burn and can continue for up to ____ hrs.

12; 36

List the physiological effects of carbon monoxide poisoning at a carbon monoxide level between 61-80% (fatal poisoning)?

Death

When a burn injury is circumferential what is a priority nursing intervention?

Assess respiratory status. This type of injury completely surrounds the chest and blood flow and chest movement for breathing may be reduced by tight eschar.

What is a priority assessment for the patient who has not been intubated whose upper airways were exposed to heat or toxic gases?

Assess the upper airway for recognition of edema and obstruction.

The type of burn occurs when chemicals directly contact the skin and epithelial tissues or are ingested.

Chemical burn

How does toxic by-products such as cyanide effect tissues?

Cyanide binds to cell energy-making components thereby inhibiting cell metabolism and cell function. Combustion of household synthetics (carpeting, plastics, vinyl flooring, upholstered furniture and window coverings) are primary sources of exposure.

Respiratory burns are a major cause of _________.

Death

This type of wound occurs with destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. This wound does not regrow, and areas not closed by wound contraction require grafting. This wound has hard, dry, leathery eschar that forms from coagulated particles or destroyed dermis. These wounds may be waxy white, deep red, yellow, brown, or black. Thrombosed vessels may be visible beneath the surface if the burn. These dermal blood vessels are heat coagulated, causing the burned tissue to be avascular (without a blood supply). Sensation is reduced or absent in these areas because of nerve ending destruction. Healing time depends on establishing a good blood supply in the injured areas. This process can range from weeks to months.

Full-thickness wounds

Direct cell injury from a burn causes what electrolyte imbalance?

Hyperkalemia. As the cell is destroyed the potassium from the cells is released into the bloodstream.

What type of fluid, electrolyte, and acid-base imbalances can result of the fluid shift and cell damage caused by a burn?

Hypovolemia, metabolic acidosis, hyperkalemia, and hyponatremia.

What nursing interventions should the nurse initiate when a burn patient in the resuscitation phase who is hoarse, has a brassy cough, drools, or has difficulty swallowing, or produces an audible breath sound on exhalation?

Immediately apply oxygen and notify the rapid response team

What are 2 priority needs for the burn patient's hypermetabolic status?

Increased need for caloric intake and oxygen.

What effect do alkalis have on tissues?

It causes the skin and it's protein to liquefy which allows for deeper spread of the chemical and more severe burns.

How does blood viscosity affect tissue perfusion?

It reduces flow through small vessels and increases tissue hypoxia.

Why is a patient's "dry," preburn weight used to calculate fluid rates, energy requirements, and drug doses?

It represents the patent's weight before edema begins to form. Height is also used to determine TBSA, which is used to calculate nutritional needs.

Why does fluid remobilization put the patient at risk for hypokalemia?

Potassium moves back to the cells and is excreted through the urine.

This type of injury occurs when people are exposed to large doses of radioactive material

Radiation injury

During this first stage of a a burn injury, the injury is evaluated and the immediate problems of fluid loss, edema, and reduced blood flow are assessed.

Resuscitation phase

These types of burns are red and moist and blanch when pressure is applied. The small vessels bringing blood to this area are injured, resulting in the leakage if large amounts of plasma, which in turn lifts off the heat-destroyed epidermis, causing blister formation. This wound increases pain sensation. Nerve endings are exposed, and any stimulation (touch or temperature change) causes intense pain. With standard care, these burns heal in 10-21 days with no scar but some minor pigment changes may occur.

Superficial partial-thickness burns

These types of wounds are caused by injury to the upper third of the dermis, leaving a good blood supply.

Superficial-partial thickness burns

This type of burn is caused by prolonged exposure to low-intensity heat (sunburn) or short (flash) exposure to high-intensity heat.

Superficial-thickness

This type of burn produces redness with mild edema, pain, and increased sensitivity to heat. Desquamation occurs 2-3 days after the burn and heals within 3-6 days without scar formation.

Superficial-thickness

This type of wound produces the least damage because the epidermis is the only part of the skin injured.

Superficial-thickness burns

________________ can reduce the healing time for deep partial-thickness burns.

Surgical intervention/skin grafting

The longer the electricity is in contact with the body, the greater the damage. How is the duration of contact increased?

Tetanic contractions of the strong flexor muscles in the forearm prevent the person from releasing the electrical source.