Burns

What should be done for patients suspected to have CO intoxication?

100% humidified O2

What is the formula for fluid resuscitation for burn patients in the first 24 hours following injury?

4mL x kg x TBSA

If burn is >10% TBSA, what is the priority for care in the emergent stage?

ABCs - airway: check for potency, soot around nares and tongue, singed nasal hair, darkened oral or nasal membranes - breathing: adequacy of ventilation - circulation: pulses, elevate burned limbs above heart

What question must you ask the patient before administering burn creams?

"are you allergic to sulfa?" many burn creams contain sulfa

How long does the emergent phase last and what are the primary concerns during this time?

- 72 hours - onset of hypovolemic shock - edema formation

How many IV access points are necessary following burn injury?

- >15% TBSA burns at least two large bore IV access points must be established - >30% TBSA - central line or arterial line

What nursing assessments are priority during the emergent phase of burn care?

- ABCs - vital signs - cardiac rhythm - LOC

What drugs are used for sedation/hypnosis in burn patients?

- Haldol: antipsychotic and sedative - Ativan: reduces anxiety - Versed: short-acting amnestic - Ambien: promotes sleep

What type of anticoagulation therapy is initiated in burn patients?

- Lovenox - (Hep-Lock)

How is TBSA determined in burn patients?

- Lund-Browder chart (most accurate) - Rule of Nines (easiest, good first assessment)

What attire must the nurse don when caring for a patient with wounds exposed?

- PPE: hats, gowns, masks, gloves - removing contaminated dressing: clean gloves - applying ointments and new dressing: sterile gloves

What drugs are used to support GI function in burn patients?

- Zantac: reduce stomach acid and curling's ulcer - Nexium - Mylanta, Maalox: neutralizes stomach acid - Mycostatin: prevents overgrowth of candid in mouth

What type of antidepressants are used in the management of burn patients?

- Zoloft - Celexa

What occurs in carbon monoxide poisoning?

- account for majority of deaths at a fire scene - inhaled CO displaces oxygen on hemoglobin causing carboxyhemoglobinemia, hypoxia, and death when CO levels >20 - "Cherry Red" - may occur in the absence of burn injury

What is a chemical burn?

- acids - alkalis - organic compounds

What is the major concern with the urianry system following burn injury?

- acute tubular necrosis: hypovolemic --> decreased blood flow to kidneys --> renal ischemia --> renal failure - myoglobin and hemoglobin released into bloodstream --> occlude renal tubules

What factors increase a patient's risk for VTE following burn injury?

- advanced age - morbid obesity - extensive or lower extremity burns - concomitant lower extremity trauma - prolonged immobility

What is the difference between acid and alkali burns?

- alkali burns are more difficult to manage because alkaline is not neutralized by tissue fluids as easily as acid substances - alkalis adhere to tissue --> protein hydrolysis and liquefication

How is the severity of electric burn decided?

- amount of voltage - tissue resistance - current pathways - surface area in contact with the current - length of time current flowed

What care is taken to protect eyes following burn injury?

- antibiotic ointments - opthalmology exam after admission - methylcellulose drops

What skin graft sources are permanent?

- autograft - cultured epithelial autograft - integra (bovine) - AlloDerm (donated human skin)

What are the two types of pain experienced by burn patients in the acute phase?

- background pain - treatment-induced pain

What are the manifestations of hyperkalemia?

- cardiac dysrhythmias - ventricular failure - muscle weakness - ECG changes

What are the three major organ systems likely to undergo complications during the emergent phase?

- cardiovascular - respiratory - urinary

What is significant about circumferential burns to the extremities?

- circulatory compromise - neurological impairment - compartment syndrome

What is involved in the inflammatory response following burn injuries?

- coagulation necrosis (tissues and vessels are damaged) - neutrophils and monocytes accumulate at site of injury - fibroblasts appear and begin wound repair within first 6 to 12 hours

What is the significance of burns to the hands, feet, joints, eyes?

- complicate self-care - jeopardize future function

How does hypernatremia develop in the acute phase?

- copious amounts of hypertonic solutions used in fluid resuscitation - tube feeding therapy - inappropriate fluid administration

What type of fluid is used for fluid resuscitation in the emergent phase?

- crystalloid such as Lactated Ringers - colloids such as albumin - combination of both

What is the result of the fluid shifts and intravascular depletion that takes place following burn injury?

- decreased BP - increased hr - shock

How is the severity of a burn determined?

- depth of burn - extent of burns by TBSA - location of burn - patient risk factors

What are the manifestations of hypernatremia?

- dried, furry tongue - lethargy - confusion - possible seizures

Describe full-thickness burns (third and fourth degree).

- dry - waxy - leathery - hard skin - visible thrombosed vessels - insensitivity to pain due to nerve destruction - possible involvement of muscles, tendon, bones - all skin elements and local nerve endings destroyed - coagulation necrosis - surgical intervention required

What are the cardiovascular complications common with burn injuries?

- dysrhythmias - hypovolemic shock - impaired circulation to extremities r/t deep circumferential burns causing ischemia, paraesthesias, necrosis, gangrene - increase in blood viscosity - microcirculation impaired

What are some of the risks associated with electric burn?

- dysrhythmias or cardiac arrest - severe metabolic acidosis - myoglobinuria --> acute tubular necrosis - immediate cardiac standstill or ventricular fibrillation

What are the phases of burn management?

- emergent: resuscitative - acute: wound healing - rehabilitative: restorative

Describe a superficial partial-thickness burn (first-degree).

- erythema - blanching on pressure - pain and mild swelling - no vesicles or blisters - tactile and pain sensation intact - superficial epidermal damage

How does hyponatremia develop in the acute phase?

- excessive GI suction - diarrhea - water intake - dilutional hyponatremia: water intoxication (have patient drink fluids other than water)

What care is given for hands and arms following burn injury?

- extended and elevated on pillow - splints to maintain positions of function

What is the benefit of early ROM?

- facilitates mobilization of extravasated fluid back into vascular bed - maintains function - prevents contractures - reassures patient that movement is possible

What are the manifestations of hypokalemia?

- fatigue - muscle weakness - leg cramps - paresthesias - decreased reflexes

What tests are used to confirm suspected inhalation injury?

- fiberoptic bronchoscopy - carboxyhemoglobin blood levels - hx of prolonged exposure to smoke or fumes - sputum that contains carbon - initial X-ray may be normal first 24 hours - ABG may be normal first 24 hours

What are possible causes for deep partial-thickness burns?

- flame - flash - scald - contact burns - chemical - tar - electric current

What is a thermal burn?

- flame - flash - scald - contact with hot object

What are some possible causes of full-thickness burns?

- flame - scald - chemical - tar - electric current

What is the result when fluid replacement is adequate at the end of the emergent phase?

- fluid loss and edema formation cease - interstitial fluid gradually returns to the vascular space - diuresis is noted

Describe deep partial-thickness burns (second-degree).

- fluid-filled vesicles that are red, shiny, wet - severe pain caused by nerve injury - mild to moderate edema - epidermis and dermis involved - regeneration remains viable

What care is given for ears following burn injury?

- free of pressure - no pillows - elevate head using rolled towel under shoulders

How is TBSA determined using rule of nines?

- front of head: 4.5% - back of head: 4.5% - front of torso: 18% - back of torso: 18% - front of one arm: 4.5% - back of one arm: 4.5% - front of one leg: 9% - back of one leg: 9% - perineum: 1%

Why is the circulatory status impaired in burn patients?

- hemolysis of RBCs by circulating factors and direct insult of injury

What skin graft sources are temporary?

- heterograft or xenograft - 3 days to 2 weeks - homograft or allograft - 3 days to 2 weeks - BioBrane - 10 to 21 days

What is the significance of burns to the buttocks or perineum?

- high risk of infection

What happens to metabolism following burn injury?

- hypermetabolic state occur - resting metabolic expenditures may increase 50 to 100% above normal - core temperature increases - catecholamines are increased - massive catabolism occurs: protein breakdown and gluconeogenesis

What are the possible reasons for altered mental status in burn patients?

- hypoxia (main reason) - head trauma - hx of substance abuse - excessive sedation or pain meds

What are the signs of impending respiratory distress?

- increased agitation - restlessness - change in character of respirations

What is a burn?

- injury to tissues of the body caused by: - heat - chemicals - electric current - radiation

What are the most common complications during rehabilitative stage?

- joint contractures: as a result of shortening scar tissue in the flexor tissue of a joint - hypertrophic scarring

What care is given for perineum following burn injury?

- keep clean and dry - catheter prevents contamination of skin

What occurs in inhalation injury below the glottis?

- lower airway injury - usually chemically produced - symptoms may not appear fro 12 to 72 hours after the burn ARDS

How is hypovolemic shock caused in burn patients?

- massive shift of fluids out of the blood vessels as a result of increased capillary permeability - water, sodium, and plasma proteins move not interstitial spaces - second spacing and third spacing - insensible losses by evaporation from skin and respiratory

What is the significance of burns to the face, neck, chest/back?

- may inhibit respiratory function r/t mechanical obstruction, edema, eschar

What drugs are used for pain control in burn patients?

- morphine - MS Contin - Dilaudid - fentanyl - Percocet - methadone - NSAIDS: Torodol - Neurontin

Why is IV the preferred method of pain med administration in the early post burn period?

- onset of action is fastest - GI function is slowed - IM will not absorb in burned or edematous areas

What criteria determines when a patient needs to be sent to a burn center?

- partial-thickness >10 TBSA - face, hands, feet, genitalia, perineum, major joints - third-degree in any age group - electrical including lightning - chemical - inhalation - preexisting disorders that could complicate management - concomitant trauma (e.g. fractures) - special social, emotional, or long-term rehab required

What is a major cause of death in patients with inhalation injuries?

- pneumonia - debilitation, abundant microbial flora, and immobility predispose patients to pneumonia

How do burn wounds heal?

- primary intention - grafting

How should chemical burns be treated initially?

- remove clothing containing the chemical - flush affected area with lots of water 20 min - 2 hours

How does hyperkalemia develop in the acute phase?

- renal failure - adrenocortical insufficiency - massive deep muscle injury (electrical burns)

What is the purpose of an escharotomy?

- restoration of circulation to compromised extremities

What is an electrical burn?

- result of intense heat generated from an electric current - direct damage to nerves and vessels - tissue anoxia and death

What is the immunological damage following burn injury?

- skin barrier is destroyed - bone marrow depression occurs - circulating levels of immunoglobulins are decreased - defects in WBCs - inflammatory cytokine cascade impairs function of lymphocytes, monocytes, neutrophils - patient is at great risk for infection

What is used to clean burn wounds?

- soap and water - normal-saline moistened gauze

What are possible causes for superficial partial-thickness burns?

- sunburn - quick heat flash

What is the significance of burns to the ears and nose?

- susceptibility to infection due to poor blood supply to cartilage

What factors determine the effects of a burn?

- temperature of burning agent - duration of contact time - type of tissue injured

What occurs in inhalation injury above the glottis?

- upper airway injury - thermally produced - redness, blistering, edema - mechanical obstruction occurs quickly - clues to this type of injury: facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, hx of being in enclosed space, and clothing burns around the check and neck

What are the two types of respiratory complications associated with burn patients?

- upper airway: burns that cause edema formation and airway obstruction - lower airway: inhalation injury r/t direct insult at the alveolar level secondary to toxic fumes or smoke

How is assessment of fluid resuscitation made?

- urine output: 0.5 to 1 mL/kg/hr or 75 to 100 mL/hr for electrical burns with evidence of hemoglobinuria ro myoglobinuria - cardiac factors: MAP > 65 mm Hg, SBP > 90 mm Hg, hear rate < 120bpm by arterial blood line

What nutritional support is given to burn patients?

- vitamins: A, C, E, multi - for wound healing - minerals: zinc, iron - promotes cell integrity and hemoglobin formation - Oxandrin - promotes weight gain and preserves body mass

How does hypokalemia develop in the acute phase?

- vomiting - diarrhea - prolonged GI suction - prolonged IV therapy without potassium supplement - constant potassium loss through wound

How can the itch associated with healing be managed?

- water-based moisturizers - Benadryl - massage oils - silicone gel sheeting - Neurontin - injectable steroids

What are the manifestations of hyponatremia?

- weakness - dizziness - muscle cramps - fatigue - headache - tachycardia - confusion

What the primary interventions in the acute phase of burn care?

- wond care - excision and grafting - pain management - physical and occupational tx - nutritional tx - psychosocial care

Can skin regenerate in full-thickness burns?

NO! re-epithelializing cells are located throughout the dermis, if this is damaged skin cannot regenerate

What GI manifestation is common in patients with large TBSA burns?

adynamic ileus - absent or decreased bowel sounds as a result of trauma and potassium shifts

How should all electric burn patients be treated initially?

considered at risk for cervical spine injury

If thermal burn is <10% TBSA, what is the initial step?

cover burn with clean, cool, tap water-dampened towel to comfort and protection

When should physical and occupational therapy take place?

during and after wound cleansing - skin is softer and bulky bandages removed

What is the best intervention for preventing Curling's ulcers?

early feeding

How do long bones become broken with electric burns?

electric current can cause muscle contractions strong enough to fracture long bones and vertebrae

Initially, what is the expected hemoconcentration of a burn patient?

elevated hematocrit caused by hemoconcentration r/t fluid loss

What is the purpose of early intubation and what patients require this intervention?

eliminates the necessity for emergency tracheostomy; major burns to face, neck, suspected inhalation injury

What does the term second spacing mean?

fluid accumulation in the interstitium

What does the term third spacing mean?

fluid moves to areas that normally have minimal to no fluid - ex: exudate and blister formation

What intervention is used to keep a scar flat?

gentle pressure maintained on the healed burn with custom-fitted garments (Jobst garments) - worn 24 hours per day for 12-18 months

What does the term slugging refer to?

increase in blood viscosity caused by fluid loss and impaired microcirculation as a result of damage to capillary system - slugging can be corrected by adequate fluid replacement

Why does hyperglycemia occur during the acute phase and what intervention is used to treat it?

increased caloric intake may cause some patients to respond with hyperglycemia; IV insulin is given - DO NOT decrease feeding

Once fluid balance has been restored, what is the expected hemoconcetration of a burn patient?

lowered hematocrit secondary to dilution

What is the accepted weight loss post-burn?

no more than 10% of pre burn weight

What does the term "iceberg effect" mean?

severity of electric burn is difficult to determine because majority of injury is below the skin

What is required for full-thickness wounds to heal?

surgical debridement and skin grafting

Why do you avoid cooling large burns?

to prevent hypothermia through extensive heat loss

How long can tissue destruction continue with chemical burns?

up to 72 hours

When are systemic antibiotics used for burn patients?

when clinical diagnosis of invasive burn wound sepsis is made or other source of infection identified (e.g. pneumonia)

When does the emergent phase end?

when fluid mobilization and diuresis begin

When does the acute phase of burn injury care begin?

with mobilization of extracellular fluid and diuresis

When does the rehabilitation phase begin?

wounds have healed and some self-care activities are resumed