Med Surg Ch 66 Burns

Zones of burn injury

*3 distinct zones* -Zone of coagulation (in the center) is where the tissue is completely destroyed, cellular death -Zone of stasis surrounds non-viable tissue and is potentially viable, compromised blood supply, inflammation and tissue injury -Zone of hyperemia has increased blood flow secondary to inflammatory response

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? A. Risk for Impaired Gas Exchange B. Acute Pain C. Infection Risk D. Altered Tissue Perfusion

A

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation? A. Myoglobin in the urine B. Increase in antidiuretic hormone (ADH) C. Elevation of blood glucose levels D. Hypernatremia

A

2nd Degree - Deep partial thickness Takes more than 3 weeks to heal May need debridement and skin grafting Scars

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2nd Degree Partial Thickness Heals in about 14 days with some pigment changes - no scaring Blanches with pressure & hair follicle remain intact No surgical intervention needed

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3rd & 4th Degree - Full Thickness Burn Destroys all layers of skin - PAINLESS Tissue is dead & charred May be a combination of red, tan, white, leathery color Must be debrided & grafted Spesis, Scaring and contractures may occur May involve muscle and bone

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ANTIMICROBIAL THERAPY Silver sulfadiazine (Silvadene) - most commonly used - watch for Sulfa allergies Mafenide Acetate (Sulfamylon) Silver Nitrate - discolors clothes black Acticoat - dressing with silver coating and can leave on up to 5 days

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Acute care Assess extent of burn injury Ventilation - trach, O2 (warmed & humidified) may need escharotomy if chest is burned Labs - ABG's, BMP/CMP, CBC, protein, BUN, GFR, Creatnine Fluid Resuscitation - LR first 24 hrs - then coilloid such as albumin/plasma - then D5W. Maintain an hourly UOPof 30 - 50 ml/hr NPO for first 24 hrs then po fluids in small amounts Mechanical ventilation, trach, hyperbaric oxygen treatment for Carbon monoxide poisoning IV analgesics - often severe pain - MS (res

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CLOSED METHOD Current preferred method. Nonadherent absorbent dressings - guaze impregnanted w/ petroleum or antimicrobials Covered with occlusive/semi occlusive dressing Dressing changed daily Chance of infection

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Compare the client's palm with the size of the burn wound. The palm is approx. 1% of a persons total body surface area

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Initial first aid - stop, drop, roll Prevent further injury (cool burn, remove metal jewlery) Observe for respiratory difficulty Airway maintenance is TOP PRIORITY

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Medical management Potential life threaening complications Inhalation injury, hypovolemic shock, infection MAJOR BURNS - transport to regional burn center

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OPEN / EXPOSURE METHOD Expose burns areas to air - used for face and perinueum Ointments Isolation Sterile environment - gloves, gown, mask, linens, bed cradle, humidified room

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SKIN GRAFTS Heterograft/xenograft (animal skin) - rejected in few days to weeks and must be removed/replaced Allograft/homograft - human skin from cadaver or human donor stem cells Autograft - clients own skin - only type of graft along with one from identical twin becomes part of patient skin

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SKIN SUBSTITUTE Temporary covering that is bioengineered Can be applied to wound once cleaned and debrided

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SKIN SUBSTITUTE & GRAFTING Purpose - lesson infection, minimize fluid loss, hasten recovery, reduce scaring, prevent loss of function Keratinocytes - regenerate epidermis Used for deep parital-thickness and full-thickness burns Problems - granulation tissue, contractures, chronic open wounds

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SURGICAL MANAGEMENT - Debridement Remove necrotic tissue - naturally/autolytic, mechanically, enzymes, surgical Disadvantage - bleeding Covering of healthy tissue - skin graft, temporary skin substitute, cultured skin

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TYPES of AUTOGRAFTS Split-thickness - epidermis & thin layer of dermis are harvested - buttocks /thighs Full thickness - includes epidermis, dermis & some subq tissue - better strength and cosmetic appearance Slit/Lace - used when don't have much of a donor site area to use

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WHIRLPOOL/HYDROTHERAPY Used to remove loose tissue and debris Water or cleaning solution used Usually done daily Analgesics before treatment (IV most effective route)

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A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client? A. Prevent infection B. Fluid resuscitation C. Endotracheal tube placement D. Strict intake and output

B

A nurse is monitoring the effectiveness of fluid resuscitation in a client who is being treated for burns. What assessment would indicate the success of the fluid resuscitation? A. The client's heart rate is rapid and regular. B. The client's urinary output is 0.5 to 1 mL/kg/hour. C. The client's breathing is unlabored, and skin is clammy. D. The client is alert and conscious.

B

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool? A. Rule of nines B. Lund and Browder method C. Hand method D. Parkland formula method

B

Following a burn to a large area of the body, the client receives an Oasis porcine graft. Which statement by the client indicates an understanding of the use of this grafting material? A. "This graft contains material obtained from a cow." B. "This graft will not become a permanent part of my skin." C. "This graft was applied with a spray gun." D. "This graft was harvested from another human."

B

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? A. Mechanical B. Natural C. Enzymatic D. Surgical

B

Which type of skin graft is more comparable in appearance to normal skin? A. Lace graft B. Full-thickness graft C. Slit graft D. Split-thickness graft

B

Fluid volume deficit occurs due to

Edema and seepage of burns

Problems that can occur with burns are

Edema, less cardiac output, hypotension

Treatment for burns is the administration of

IV LR 7 albumin

3rd spacing occurs when too much fluid moves from

Intravascular (plasma) into Interstitial (3rd Space)

Vital signs

Pulse up Blood Pressure Down Cardiac output Down Urine output Down Potassium Up Hermatocrit Up WBC Down BUN/Creatnine UP

Infection prevention measures - Staph Aureus - most common Pseudomonas Candida

Sterile tecnique, clothing removed, debris removed, hair clipped, ruptured blisters clipped off, burns cleansed and topicals applied

rule of nines Head is Back 4.5% Front 4.5% = 9 Each Arm Back 4.5% Front 4.5% = 9 x 2 Each Leg Back 9% Front 9% = 18 x 2 Torso 18% Front 18% = 36 Genitals 1%

Way of assessing % of burn injury - Total body surface area

Burns from heat cause

cell damage, protein coagulation

Chemical burns (cellular) - electrolyte alteration - loss of

extracellular protein

Fluid shift that occurs immediately after a serious burn

fluid shifts from vascular to interstitial and intracellular spaces because of increased capillary pressure

ACTH stimulation is due to stress that causes the release of _____ (think hyperglycemia)

glucocorticoids

Causes of burns

heat, chemical, electricity

total parenteral nutrition (TPN)

nutrient-complete solution given directly into bloodstream when person cannot eat by mouth

Movement of fluid causes shift from

plasma to interstitial space (third spacing)

Superficial - 1st degree Epidermis is injured but the Dermis is intact Red, painful edema that goes away quickly Heals in 5 days

sunburn

Biobrane

synthetic dressing composed of a nylon, Silastic membrane combined with a collagen derivative

The severity of heat burns is based on

temperature, duration of contact, thickeness of tissue, location

Area where burn is most sever and deepest

zone of coagulation

Skin substitutes are often used after the wound is debrided and cleaned. What is the purpose(s) for the use of a skin substitute? Select all that apply. A. Lessen potential for infection B. Maximizes fluid loss C. Promotes granulation of tissue D. Covers the unattractiveness of the wound E. Slows regeneration of tissue F. Diminishes pain

A, F

_______ and _____ are produced in serious burns

ACTH, ADH

Curling's ulcer

Acute gastric ulcer associated with severe burns

The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply. A. Wear the garment at least 12 hours each day. B. Contact the primary provider if the garment does not seem to fit properly. C. Machine wash the pressure garment daily with a mild detergent. D. Roll the garment and wring tightly to ensure garment is as dry as possible after washing. E. Massage any

B, E

What is a benefit(s) that supports the use of a closed method wound care in the management of a client with burns? Select all that apply. A. Provides a drier environment B. Promotes heat loss C. Creates microbial barrier D. Prevents exudate accumulation E. Reduces pain during position changes F. Promotes slower healing

C, E

The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts? A. Less scarring B. Less discomfort C. Speeds healing D. Rejection is unlikely.

D

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? A. Tissue hypoxia B. Infection C. Renal failure D. Hypovolemia

D

Fluid moves from body to the burned area and fluid is also lost from the burned area - this causes

Decreased BP & Increased Pulse (Shock)

Oftne with burns 3rd spacing occurs due to loss of _______ which affects colloidal osmotic pressure

albumen

Electrical/lightening burns can cause

dysrhythmias, CNS complications