Med-Surg II Final- Burns

Tetanus Shot

Tetanus Toxoid I.M. is given to all major burn victims to fight anaerobic contamination of burn wounds

Deep Burn

Second Degree Burn - Epidermis and dermis are affected - Very Painful - Moist or dry red blisters form - Pale color

Rules for treating infection in Burn Patients

#1: Burn trauma patients will be exposed to microorganisms no matter how germ free the environment #2: No single antibiotic or combo of antibiotics will fight all organisms #3: First the bug then the drug - do culture to determine the bacteria b/c bacteria will determine what kind of antibiotic to use

Hypothermia (1Q)

Alteration in body temp related to loss of skin - Set the thermostats at a warm temperature in the room - Avoid drafts - Place heat lamps or warming lights over the pt's bed PRN

Emergent Phase

A.K.A Fluid Accumulation Phase Time from onset of burns to the beginning of fluid remobilization Usually lasts 24-28 hours Immediate problem is fluid loss, edema, reduced blood flow (fluid and electrolyte shifts) Greatest threat to major burn victim is hypovolemic shock - Assess the respiratory system by inspecting the mouth, nose and pharynx. -Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present Watch for change in respiratory pattern which may indicate pulmonary injury; pt. may: - Become progressively hoarse - Develop brassy cough - Drool or have difficulty swallowing - Produce expiratory sounds: audible wheezes, crowing and stridor; intubate patient - If wheezes disappear, this indicates impending airway obstruction and demands immediate intubation; same with stridor Urine output is decreased during the first 24 hours of this phase Fluid resuscitation is provided at the rate needed to maintain adult urine output 30-50ml/hr Measure BUN, Creatinine, and NA levels - if you want to know if organs are being perfused check the kidney function Peripheral edema = extremities edema: check the capillary refill to determine, if the cap. refill time is greater than (>) 3 sec. then edema is present. DO NOT GIVE DIURETIC to increase urine output b/c it will decrease the cardiac output and circulating volume by pulling fluid from the circulating blood volume to enhance diuresis Elevate the burned arms on pillows to prevent edema

Which of the following burn victims should the nurse assess for carbon monoxide inhalation? a. Was found unconscious in a burning building b. Has facial burns, hoarseness, and sooty sputum c. Inhaled a large amount of steam released by a radiator d. Was burned in a charcoal grill fire ignited with gasoline

ANS: A

A client comes to the clinic experiencing thirst, dizziness, nausea, headache, and profuse sweating after running a 10K race on a day when the outside temperature was 98 degrees F. What stage of heat illness should the nurse suspect? a. heat cramp c. heat fatigue b. heat exhaustion d. heat stroke

ANS: B The four stages of heat illness are (1) heat fatigue, which causes thirst, feelings of weakness, or fatigue (2) heat cramp which causes leg cramps and thirst (3) heat exhaustion, which causes thirst, dizziness, nausea, headache, and profuse sweating (4) heat stroke, which involves fever and could produce brain and kidney damage

A client is admitted to the emergency department after suffering an electrical burn from exposure to a high-voltage current. In addition to the burn injuries, what should the nurse initially assess for the presence of? a. Renal failure b. Cerebral edema c. Spinal fractures d. Metabolic alkalosis

ANS: C Contact with electric current can cause muscle contractions strong enough to fracture the long bones and the vertebrae. Another reason to suspect long bone or spinal fractures is a fall. Most electrical injuries occur when the victim is elevated above the ground and comes in contact with a current source. For this reason, all clients with electrical burns should be considered at risk for a potential cervical spine injury. Cervical spine immobilization should be used during transport and subsequent spinal X-ray films made to rule out any injury.

The nurse determines that fluid replacement for a client with major burns is adequate based on which of the following findings? a. A stable weight b. A blood pressure of 90/58 mm Hg c. A urinary output of 40 mL/hr d. An intake equal to urinary output

ANS: C Urinary output is the most commonly used parameter for assessment of adequacy of fluid replacement. A normal finding is a urinary output of 30 to 50 mL/hr in an adult.

Which is an appropriate intervention during the emergent phase of a client with extensive burns to address the nursing diagnosis of imbalanced nutrition? a. An oral intake of 5000 kcal per day b. Intravenous administration of multivitamins and minerals c. Administration of total parenteral nutrition via a central catheter d. Continuous enteral feeding via a feeding tube positioned in the duodenum

ANS: D During the emergent phase of a client with extensive burns, the nurse should administer enteral feedings to provide nutrition until oral intake can be resumed.

Which of the following laboratory results should the nurse monitor closely in the client during the acute phase of burn injury? a. Hematocrit and serum sodium b. Serum albumin and hematocrit c. Serum potassium and hematocrit d. Serum sodium and serum potassium

ANS: D Sodium and potassium are involved in electrolyte shifts; therefore, sodium and potassium need to be monitored closely during the acute phase of the burn injury. Sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases (see Figure 26-6). A potassium shift develops initially because injured cells and hemolyzed red blood cells release potassium into the extracellular spaces.

Wound Care - Open Method

Apply topical antimicrobial creams/solutions to the wound Advantages: - No painful dressing changes - Visible for assessing wounds for signs of infections -LESS EQUIPMENT = LESS COST Disadvantages: - Not suitable for burns of hands and feet - More difficult to control body temperature - Difficulty when transferring patients

Wound Care - Closed Method

Apply topical chemotherapy and wrap with gauze, fluffs, kerlix Assess for constriction, circulation checks - Check by getting close to the burned area and checking for radiating heat

Types of Grafts

Autograft or Autologous: SELF (permanent) Heterograft: Different Species - ex: Pig, Bovine (permanent) Homograft: from a Cadaver (temporary) Synthetic Graft: Biobrane Integra: Bovine collagen (Permanent) Alloderm: Derived from donated human skin Cultured Epithelial Autograft (CEA): unburned skin biopsied and sent to lab to grow with epithelial growth factor added

Acute Phase

Begins after 48-72 hours beginning of diuresis and concludes when wound is covered or healed, Lasts until wound closure is complete (could take weeks to months) -Fluid begins to shift interstitial spaces back into bloodstream or intravascular space; AVOID FREE WATER - Ends when TBSA <20% by grafting or wound healing Care is directed toward continued assessment and maintenance of the cardiovascular and respiratory system Daily weights without dressings or splints and compare to pre-burn weight - 2% weight loss indicates mild deficit; 10% or greater weight loss requires modification of caloric intake Tetanus toxoid injection; monitor for signs of infection To prevent infection apply topical antibiotics after wounds are cleaned and debrided Pneumonia is a concern b/c can result in respiratory failure requiring mechanical ventilation - Auscultate lungs

Rehabilitative Phase

Begins with wound closure and ends when the pt. returns to the highest possible level of functioning - Provide psychosocial support - Assess home environment, financial resources, medical equipment, prosthetic rehab - Health teaching should include symptoms of infection, drug regimens, follow-up appointments, comfort measures to reduce pruritus (itching) Instruct client on skin care: - Skin will itch, be dry, have a tight feeling - Use Vaseline intensive care ES lotion, mild soaps - Avoid direct sunlight (will cause hyperpigmentation) - Skin may be hypo or hyper sensitive to cold/heat/touch - Diet (high proteins, vitamins) - Exercise to prevent contractures - Instruct client on signs and symptoms of infection Instruct client to wear JOBST pressure garment for up to 1 year - Need to wear JOBST to prevent Keloid formation

Fluid Shift

Blood vessels dilate and leak fluid into the interstitial space; area around the burn is dilating Known as third spacing or capillary leak syndrome; causes decreased blood volume and blood pressure Occurs within the first 12hours after the burn and can continue to up to 36 hours Patient needs fluid resuscitation

Chemical Burn

Burn from a chemical source Remove the person from contact with the chemical agent Remove the affected clothing if possible

Graft Survival

Depends on: - Recipient skin bed must have adequate blood supply - Graft must be in close contact with the recipient's skin bed - Graft must be immobilized - Free from infection

Parkland Baxter Formula (1Q)

Calculate the amount of fluid needed for resuscitation

Thermal Burns

Caused by flame, flash, scald or contact This is the most common type of burn Interventions: - STOP, DROP & ROLL - Roll to shut off the oxygen supply to the fire - Flush or immerse the area in cold water - DO NOT USE ICE on any burns, especially deep burns, may use it on localized or artificial burns - Cover the patient with a clean cover - DO NOT PULL OFF CLOTHING; CUT IT OFF to prevent tearing off skin - KEEP NPO and transport the patient NPO because pt. is in shock and you don't want the pt to have anything until you know the extent of the burn and what is affected

Electrical Burn

Coagulation Necrosis :cell death Severity depends on voltage, amount of resistance, time, and the pathway of the electrical current Frequently only the entry (yellow-white) and exit (blow out) wounds are visible - small entry big exit wounds The electrical current can be strong enough to fracture long bones and cause respiratory muscles to contract Interventions: - Turn off the source of electricity if possible - Remove the current with a dry piece of wood - Initiate CPR and Transport the patient NEVER TOUCH/USE ANYTHING METAL

During the acute phase of burn treatment, important goals of patient care include which of the following? Select all that apply. 1. providing for patient comfort 2. preventing infection 3. providing adequate nutrition for healing to occur 4. splinting, positioning, and exercising affected joints 5. assessing home maintenance management

Correct Answer: 1,2,3,4 Rationale: The goals of treatment for the acute period include wound cleansing and healing; pain relief; preventing infection; promoting nutrition; and splinting, positioning, and exercising affected joints.

Acute Phase Interventions and Goals

Daily weights Monitor lab values Auscultate lungs Fluids as ordered Avoid free water - dilutional hyponatremia Monitor bowel sounds High protein; High Carbohydrate Assess food preferences TPN as ordered Assess pt.'s readiness to talk Allow pt. to work through grief process Give honest, accurate information ROM Exercises Always maintain eye contact with patient

Topical Antimicrobial Agents

Does not sterilize the burn but reduces the number of bacteria so that the microbial count is controlled by the body's defense mechanisms The effectiveness is based on wound cultures (done weekly); what kind of bacteria Different antimicrobial agents are used at different times during the acute phase Silvadene (Silver Sufadiazine) water soluble cream: - Most bactericidal agent; most common - Minimally penetrates through eschar - Watch for leukopenia (decreased WBC) Silver Nitrate Solution - Bacteriostatic and funicidal - Does not penetrate eschar - Monitor serum sodium and potassium levels - Stains everything it touches black Mafenide Acetate (Sulfamyion acetate) - Used with electrical burns - Can penetrate the thick eschar associated with this type of burn - Effective against gram-negative and gram-positive organisms - Monitor arterial blood gases; discontinue if there is acidosis; reduces renal buffering and causes metabolic acidosis

Debridement

Done Everyday Done with forceps and curved scissors or through hydrotherapy (application of water for treatment; water is heated to approximately 104 degrees) - Hydrotherapy continually washes away dead skin and bacteria, minimizing a pt.'s risk of infection Only loose eschar is removed - Eschar is removed until viable tissue is reached Blisters are left alone to serve as a protector (controversial)

Skin Grafts

Done during the acute phase Used for deep partial-thickness (2nd degree) and full-thickness (3rd degree) wounds Post care: - Maintain dressing - Use aseptic technique - Graft should look pink if it is after 5 days - Skeletal traction may be used to prevent contractures - Elastic bandages may be applied for 6 mos. to 1 yr to prevent hypertophic scarring Reasons for grafting: - Survival - Function - Cosmetic

Phases of Burns

Emergent Acute Rehabilitative

Superficial Burn

First Degree Burn - Epidermis is affected - Can be caused by UV light, the Sun, Mild radiation - Pink to red color - Slight edema - Mild pain Example: Sunburn

Stages of Heat Illness (1Q)

Heat Fatigue Heat Cramps Heat Exhaustion Heat Stroke

Fluid Imbalances

Hypovolemia Metabolic Acidosis Hyperkalemia: potassium is coming out of the damaged cells and other cells are taking it up Hyponatremia: because of fluid loss, the degree of hyponatremia depends on the severity of the burn Hemoconcentration (elevated blood osmolarity): due to dehydration, large concentration with small fluid

Monitor Lab Values

NA - Hypernatremia or Hyponatremia K - Hyperkalemia or Hypokalemia WBC - 10,000-20,000

Goals of Treatment

Prevent complications (contractures) Vital signs hourly Assess respiratory function Tetanus booster Anti-infective drugs Analgesics No Aspirin Strict surgical asepsis Turn Q2H to prevent contractures Emotional support

Symptoms of Heat Stroke

Primary symptom: body temperature higher than 105 degrees Fahrenheit or 40.6 degrees Celsius. Other symptoms: warm and dry skin, fever, increased heart rate, shallow breathing, loss of appetite, nausea, vomiting, throbbing headache, dizziness, light-headedness, fatigue, confusion, muscle weakness or cramps, agitation, lethargy, stupor, lack of sweating, and in worst case scenarios, seizures, coma and death.

Common Fluids

Protenate or 5% albumin in isotonic saline: 1/2 given in the first 8hr; 1/2 given in the next 16hr; albumin is a colloid - Albumin keeps fluid in the circulatory system Lactated Ringer's (LR) without dextrose: 1/2 given in the first 8hr; 1/2 given in the next 16hr Crystalloid (hypertonic saline): adjust to maintain urine output at 30ml/hr Crystalloid only then give Lactated Ringers

Emergent phase complications

Renal failure: - Due to hypovolemia decreased blood flow to kidneys causing renal ischemia; Acute renal failure may develop. - Can be developed from full-thickness (3rd degree) and electrical burns. - Myoglobin from muscles and Hgb from the breakdown of RBCs are released into the bloodstream and gets caught in the glomerulus and blocks the renal tubules - Use foley catheter to monitor urine output: should be 30ml/hr Frequent V/S - Systolic BP should be at or above (>) 100 - Pulse should be at or below (<) 100 - Respiratory rate should be between 16-20 Cardiac Function: - Arrhythmias due to electrolyte imbalance or electrical burns - Hypovolemic shock due vascular bed depletion

Burns/Joints (1Q)

Require intensive therapy to prevent disability such as contractures, etc. Perform ROM exercises

What are the 4 degrees of burns? (1Q)

Superficial Deep Full thickness (3) Full thickness (4)

Types of Burn Injury

Thermal Chemical Electrical Radiation

Full thickness Burn

Third degree burn Fourth degree burn is all the way to the bone and organs; the bone can be crispy - Epidermis, Dermis and Subcutaneous tissue are burned - Nerve endings are destroyed so pt. may have little or no pain in the burn area - Requires immediate hospitalization - Dry, waxy white, leathery, hard skin - No pain - Exposure to flames, electricity, or chemicals can cause these 3rd and 4th degree burns

Rule of 9s (1Q)

Total body surface area (TBSA) burn calculation Superficial burns are not included in the calculation

Fluid Replacement (1Q) IV Fluid Therapy

infusion of IV fluids is needed to maintain sufficient blood volume for normal cardiac output Pt. with burn TBSA 15-20% require IV fluid Purpose: to prevent shock by maintaining adequate circulating blood fluid volume The more severe the burn the more fluid needed to maintain blood flow to vital organs Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital

Symptoms of Heat Exhaustion

muscle cramps, pale and moist skin, fever, nausea, vomiting, diarrhea, headache, dizziness, fatigue, weakness, anxiety, heavy sweating and rapid pulse

Symptoms of Heat Cramps

painful cramps, particularly in the legs, red and moist skin and dark-colored urine

Symptoms of Heat Fatigue

thirst, feelings of weakness, or fatigue