Burns

Thermal burn

***most common type caused by flame, flash, scald, or contact with hot objects

burn shock is characterized by

-Capillary leak -third spacing -severe hypovolemia -decreased cardiac output

superficial partial thickness burn ex

-blisters -blanching

pulmonary alteration risk factors

-burn occured in closed areas -burn of the face or neck -singed nasal hair -increased restlessness, agitation, or anxiety -hoarseness, voice change, dry cough, stridor -sooty or bloody sputum -labored breathing, tachypnea, or signs of hypoxemia -erythema and blistering of the oral or pharyngeal muscosa

later electrolyte alterations

-hypokalemia- due to fluid shift and inadequate K replacement -Lactic acidosis- due to hypovolemia and hypoperfusion

initial electrolyte alterations

-hyponatremia- loss of intravascular volume -hyperkalemia- due to cellular destruction

other system alterations

-immune system- normal defenses lost, high risk sepsis -thermoregulation- inability to regulate temperature

deep partial thickness burn ex

-little to non-blanching

acute/intermediate phase therapies

-topical antibiotic therapy -debridement

full thickness burn ex

-waxy white, yellow or black -decreased pain

genitals %

1

GI alterations

1) paralytic ileus- absence of intestinal peristalsis 2) Curlings Ulcer- gastric or duodenal erosion

chest %

18

arms %

4.5

head %

4.5

legs %

9

A severely burned client hospitalized for 3 days is now experiencing the acute phase. Recovery has been uneventful, but now the client has begun to exhibit extreme restlessness. Which complication would the nurse conclude the client is most likely developing A) kidney failure B) cerebral hypoxia C) metabolic acidosis D) hypovolemic shock

B

For a client admitted into the hospital with partial and full thickness burns of the chest and face obtained while attempting to extinguish a brush fire, which concern would the nurse take priority? A) Loss of skin integrity caused by the burns B) Potential for infection as a result of the burn injury C) inadequate gas exchange caused by smoke inhalation D) Decreased fluid volume because of the depth of the burns

C

When providing care for a client during the first few hours after admission to the burn unit with full thickness burns of the trunk and head, which goal is the nurses priority during the emergent phase of this injury A) preventing pain B) managing leukopenia C) preventing infection D) Managing fluid loss

D

Lund-Browder Chart

Most accurate method for estimating burn extent, & must be used in the evaluation of all pediatric patients

Emergent/Resuscitative Phase

Onset of injury to completion of fluid resuscitation -circulation- BP/HR, urine output, fluid resuscitation - airway- establish airway immed!!! ET tube? -breathing- 100% humidified oxygen, intubation/ventilation, RR, lung lung sounds, o2 sat -disability- assess neurologic status, GCS

what solutions are used to bring fluid back into intravascular space

albumin or colloid IV solutions -not started until 12-24 hours after injury or when capillary permeability returns to normal

Acute/Intermediate Phase

beginning of diuresis to wound closure -Begins when patient is hemodynamically stable 48-72 hours after -maintain circulatory and respiratory status -infection prevention -wound care -pain management -nutritional support -promoting mobility -psychological and emotional support

radiation burn

caused by UV rays, x-rays, or radiation therapy

chemical burn

contact with acids, alkalis, and organic compounds

renal alterations

due to decreased blood volume nurses should monitor -BUN -Creatinine -urinary output

cardiovascular alterations due to burns

dysrhythmias and shock are most common

greatest initial threat of burns

hypovolemic shock!!! capillary walls become permeable causing fluid to move into interstitial space and tissues leading to third spacing

preferred IV solution for fluid resuscitation

lactated ringers

The goal of fluid resuscitation

provide enough fluid to maintain circulation -titrate based on urine output

Acute/intermediate phase pain management

provide some control over wound care and analgesia

electrical burn

result from intense heat generated from an electric current

superficial thickness burn ex

sun burn

Rehabilitation phase

wound closure to return to optimal level of adjustment ends when patient returns to highest possible level of functioning