BURNS

How do you treat carbon monoxide poisoning?

100% O2 through mask or ETT 1/2 life of CO 40-60 min with 100% O2 Pulse ox & ABG's not reliable in this case

*A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. TBSA burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient is placed on mechanical ventilator support. The nurse is aware that inhalation injury predisposes the patient to the development of

ARDS. Inhalation injury predisposes the patient to the development of pneumonia and acute respiratory distress syndrome (ARDS). Management of ARDS necessitates mechanical ventilatory support and, in extreme cases, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation.

*A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What do you do first?

Assess the airway and provide 100% oxygen. The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

*Which of the following would prevent cross-contamination by direct contact and decrease the risk of infection in the burn-injured patient?

Changing gloves and hand washing should be done when moving from area to area on the same patient. Cross-contamination by direct contact is a significant source of infection and a subsequent cause of sepsis. Effective hand-washing technique cannot be overemphasized. Nurses must wash their hands and change gloves when moving from area to area on the same patient.

*A patient has full-thickness burns to his face, chest, back, and bilateral upper arms. He was injured less than 24 hours ago. He sustained these injuries in a house fire and is presumed to have inhaled smoke and sustained an inhalation injury as well. He was nasally intubated in the emergency department and placed on mechanical ventilatory support. He is now showing signs of increasing agitation and is demonstrating high peak airway (ventilatory) pressures. What is the likely cause in this change in his condition?

Decreased pulmonary compliance Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.

*A red and white wound surface with blanching but no blister formation describes what depth of burn injury?

Deep dermal partial-thickness burn

*A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. TBSA burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The nurse should have a high suspicion for myoglobinuria with which type of burn injury?

Electrical burn The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

*A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. TBSA burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse signal in the right arm on admission of this patient. What immediate intervention is needed?

Escharotomy An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel.

how do you preserve renal function?

Hydrate while maintaining urine output 30-50 cc/hr,

*A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. TBSA burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient is now in the intensive care burn unit with a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. The fluid resuscitation plan

IV rate should be increased and fluid status closely watched. Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/hr; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus.

*A leading cause of death in the hospitalized burn patient

Infection

how do you manage pain?

Initial IV Morphine (opiates), later oral never IM or SQ address early - reassess frequently

one of the most important nursing actions for a pt with severe burn injury is?

Monitor VS & urine output trends/patterns

how do you manage gastrointestinal function?

NG or OG to prevent abd distention, emesis & potential aspiration, give prophylaxis meds to prevent stress ulcers, monitor for paralytic ileus

*What is the likely depth of injury in a patient with injuries described as moist and red with some blister formation and very painful?

Partial-thickness, second-degree burn A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

*According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.)

Perineum Genitalia Face

*Which of the following causes can lead to excessive burn edema and shock in a patient with injuries totaling more than 50% -TBSA burn?

Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.

*This phase occurs 4 to 20 days after injury and involves rapid synthesis of collagen.

Proliferative phase The key cell in this phase of healing, the fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound.

Burn nursing management phases

RESUSCITATION - cardiopulmonary instability, life threatening airway & breathing problems & hypovolemia - repletion of plasma volume, maintain vital organ function & perfusion ACUTE CARE - begins after resuscitation & lasts until complete wound closure - wound healing, wound closure, prevention of infection REHABILITATION - recuperation & healing, not acutely ill, may last for years, scar management techniques, PT & OT

*Which of the topical antimicrobial agents is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria?

Silver sulfadiazine

*Procedural pain control is best achieved with the use of what strategies during the early phase (first 24-48 hours) of recovery in the patient with a major burn injury?

Small doses of intravenous opioids titrated to effect Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful.

Parkland Formula

TBSA determines how much fluid needed. LR 1st, fluids given to maintain UO of 30-50 ml/hr (don't under or over hydrate). **NEED 30** Give 50% of fluids in first 8 hours, give 25% of fluids in the next 8 hours, give 25% in third 8 hours. After 24 hours, capillary leaks heal and colloids such as albumin, dextran & fresh frozen plasma may be given to decrease edema & correct fluid status

*Which phase begins immediately after injury?

The inflammatory phase begins immediately after injury. Vascular changes and cellular activity characterize this period. Changes in the severed vessels occur in an attempt to wall off the wound from the external environment.

*In which phase does the wound develop tensile strength?

The maturation phase, or remodeling phase, of healing occurs from approximately 20 days after injury to longer than 1 year after injury. During this period, the wound develops tensile strength as collagen deposits form scar tissue.

*Which zone is the site of the most severe damage?

Zone of coagulation The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

Which zone is the outer most area?

Zone of hyperemia - has vasodilation and increased blood flow, but min. cell involvement. Early spontaneous recovery can occur.

Which zone is potentially salvageable?

Zone of stasis - characterized by impaired circulation, can lead to cessation of blood flow caused by pronounced inflammatory reaction.

Absolute & relative hypovolemia

absolute- fluid leaves the body d/t an external source relative - loss of fluid from shifting from intravascular to extravascular space

Chemical burn

acid or alkali agent concentration of agent, duration of exposure are key to depth may take up to 48 hours to show full extent of burn treatment: flush with water LARGE amounts remove clothes & shoes if contact with chemical avoid chemical antidote - cause exothermic

*A patient involved in a house fire is brought by ambulance to your emergency department. He is breathing spontaneously but appears agitated. He does not respond appropriately to questions. You assume he has inhaled carbon monoxide and has carbon monoxide (CO) poisoning. Your first action is to

administer 100% high-flow oxygen via a nonrebreathing mask. The treatment of choice for CO poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen.

Airway management is a must!

always consider inhalation injury with facial burns, can be caused by; carbon monoxide, direct heat, & chemicals. Injury to trachea & main bronchi often follows inhalation injury. Inhalation predisposes pt to develop PNU & ARDS ALWAYS INTUBATE if airway patency is questionable

Escharotomies

burn eschar incisions - may be needed immediately to increase compliance & for improved ventilation

2nd degree - deep partial thickness

can go through melanin (no color on skin after burn) - not as painful, may blister superficial with deep layers of dermal layer affected contact with hot liquids or solids, intense radiant energy wound surface red with patchy white areas, blanch with pressure. Appearance changes over time. Prolonged healing time - up to 6 weeks can become full thickness if becomes infected or blood supply is diminished (further trauma)

*Which of the following is most important when determining whether or not to refer a patient to a burn center?

d. The medical history of the patient and the size and depth of the burn injury Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center.

*Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing actions concerning this therapy include

daily assessment for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times except to assess the graft site for pressure points every shift.

*Management of full-thickness burns includes

daily wound care with premedication of narcotics. Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection. Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients should receive adequate premedication with analgesics, narcotics, or other sedatives.

3rd degree - full thickness

destruction of all layers of skin, down to & including subcutaneous tissue, appears pale white or charred. red, brown, leathery usually painless & insensitive to palpation will not heal by re-epithelization - need skin graft extremely susceptible to infections, fluid & electrolyte imbalances, alterations in thermoregulation & metabolic disturbances

Electrical burn

electric or lightening - low or high voltage can cause tissue necrosis/death remove source ASAP, but safely can cause internal injury such as fx of bone, cardiac arrest (monitor with EKG), metabolic acidosis (lactic acid buildup d/t muscle damage), acute tubular necrosis (due to myoglobin released with muscle injruy) treatment: give LR (fluid replacement), mannitol (diuretic to flush out kidneys), NaHCO3 (sodium bicarbonate for acidosis)

4th degree - full thickness + deep structures

extensive damage to deep structures like muscle & bone presentation similar to 3rd degree, but with extensive destruction often don't survive - rarely seen alive BAD NEWS

Third spacing

fluids may pool on the burn site (lying outside of the interstitial tissue, exposed to air & will evaporate) & cause depletion of the fluids. Also increase vascular permeability d/t inflammatory response, which leaks fluid into extravascular space. 3rd spacing causes hypotension, increased HR & edema

Rules of Nine - adults only

head = 9% one arm = 9% one leg = 18% torso = 36% genitals = 1%

*A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. TBSA burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. Other important nursing interventions for this patient in the resuscitation phase include

intravenous opiates and assessment of pulses in both arms. Pain management in burn injuries must be addressed early and frequently reassessed to determine the adequacy of interventions. Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation.

1st degree burn - superficial

involves epidermis erythema & mild discomfort pain is chief symptom - resolves 48-72 hours heals 2-7 days, no medical attention generally swelling common complication sunburns, minor steam burns

Loss of albumin

massive protein loss from the burn site & increased vascular permeability d/t inflammatory response. Fluid containing plasma proteins/albumin, water & sodium (watch for hypocalcemia Ca follows albumin) leaks into extravascular space

*Your patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). Frozen and then thawed pigskin is used at your institution. The nurse knows that pigskin is removed in 5 to 7 days because

of lack of blood supply. After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary coverage of full- and partial-thickness wounds, burn wounds, and donor sites.

2nd degree - partial thickness

painful, red, blisters superficial with top of dermal layer affected caused by brief contact with flames, hot liquid or exposure to dilute chemicals light to bright red, mottled appearance may appear wet & weeping extremely painful & sensitive to air currents blanch painfully, heal 7-21 days

Why is ROM so important with burns?

prevent contractures, pressure ulcers, and DVT's

what is a common affect of skin grafts?

pruitis - itching

*Priorities in the rehabilitation phase of burn management include

recuperation and healing physically and emotionally.

what is a autograft

skin harvested from a healthy, uninjured area of pt, placed over wound to provide permanent coverage -only graft that provides permanent coverage

what is homograft/allograft?

skin harvested from live or deceased donors

what is heterograft/xenograft?

skin transferred from between 2 different species to provide temporary wound coverage - usually pig skin

*Split-thickness skin grafts (autografts) are used to cover deep partial-thickness burn injuries because

split-thickness skin grafts provide a better cosmetic and functional result than does the natural healing in these injuries. Autografts are the only grafts that provide permanent wound coverage. Sheets of the patient's epidermis and a partial layer of the dermis are harvested with use of a dermatome. These grafts are referred to as split-thickness skin grafts and can be applied to the wound bed as a sheet or in meshed form. Grafts that are placed on the face, neck, lower portions of the arms, and hands are sheet grafts when possible. Grafts that are meshed can cover more area but may not produce the cosmetic appearance desired; therefore, they are usually placed on areas covered by clothing.

Thermal burn - most common

steam, scald, (fires, space heater, boiling water) smoke inhalation a concern can have severe edema to face airway management early prophylactic endotracheal intubation is paramount cool injury immediately with cool running water to stop burning process

what type of burn is edema unique to

thermal burns

what is biobrane?

type of biosynthetic skin graft that adheres to wound fibrin. Very porous which allows meds & antibiotics to be absorbed through it

Radiation burn

uncommon usually localized & indicate high radiation doses to affected area. appear identical to thermal can take days to weeks to show up

*A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. TBSA burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient is now in the intensive care burn unit with a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. The patient's symptoms are most likely attributable to

under-resuscitation because of probable inhalation injury. The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated. Under-resuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury. Over-resuscitation may lead to moderate to severe pulmonary edema; to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal portions of the extremities; or to edema inhibiting perfusion of the zone of stasis, resulting in wound conversion.