Burns

Lower airway injury

inhalation injury to trachea, bronchioles, and alveoli Usually caused by toxic chemical or smoke s/s dyspnea, carbonaceous sputum, wheezing, hoarseness, altered mental status

Manifestations of hypernatremia include:

thirst/dry mouth lethargy confusion possible seizures

Prehospital-Wounds less than 10% of TBSA

Stay at local hospital, probably in the ICU- especially if intubated If not needed to intubate, put on O2 on non-rebreather mask Take ABGs Think Fluids and electrolytes (second and third spacing-- edema)

Superficial Burn

Sunburn; A thermal burn involving the epidermis that is characterized by redness and pain

Calculation of percentages

Superficial burns are not implemented into calculating percentages

Compartment Syndrome

Swelling and constriction Underneath the scar tissue fluid shifts Blood cell lysis Capillary leak

Emergent phase Nutrition

--After fluid replacement has been initiated, nutrition takes top priority in the initial emergent phase --Typically nonintubated patients are able to eat enough to meet their nutritional needs --As for intubated patients, some additional support is required. Enteral feeding are typically chosen over parenteral feeding --feedings should include increased calories and proteins to avoid malnutrition and delayed healing --Provide patients nutritional supplements and milk shakes to help meet caloric requirements --You can also add protein powder to food and liquids and start the patient on supplemental vitamins

Nursing wound treatment for a patient sustaining a 2nd degree/partial thickness burn Emergent Phase

--Start daily shower and wound care --Debride as necessary --Assess extent and depth of burns --Administer tetanus toxoid or tetanus antitoxin --Assess for the need of an escharotomy and fasciotomy --Open vs. closed method of wound treatment ---->Open- use a topical antimicrobial and no dressing Wear PPE Nonsterile gloves to clean wound and sterile gloves when applying ointment and new dressings ---->Closed- sterile gauze dressings are impregnated with or laid over a topical antimicrobial Dressings are changed every 12/24 hours to 14 days depending on the product used Assess to see if patient needs skin grafting

Nursing wound treatment for patient sustaining a 1st degree/superficial burn

--Superficial burns involve the epidermis but the blood supply to the dermis is still intact. --CAUSED by sunburn or minor thermal injuries --Wounds are cleansed by immersion, showering, or spraying. You can clean them with soap and water or normal saline-moistened gauze to remove old antimicrobial agents or any loose scabs or dried blood. --Cover wound with topical antimicrobial creams like silver sulfadiazine or a sliver impregnated dressings. --Assess wound daily for any infection and change the dressing often --This type of burn will usually heal within 3-6 days depending on how bad it is

Nursing management and treatment for crystalloid fluid replacement in the Emergent phase in respect to IV sites, urinary output, and cardiac factors.

2 large bore IV sites required if 15% or more of total body surface area (TBSA) burned Place in a non-burned area with large veins If no unburned areas are available IVs can be placed in a burned area or an interosseous line may be started Avoid securing an IV in a burned area with tape or adhesives Central line recommended if >30% of TBSA burned Arterial line recommended if frequent ABGs or invasive BP monitoring needed Lactated Ringer's is the preferred solution for fluid resuscitation in burn patients Initiate a Foley catheter to monitor urine output Evaluate effectiveness of fluid resuscitation hourly using pre-set clinical parameters for cardiac status and urine output Urine output: 0.5-1.0ml/kg/hour Cardiac: MAP >65mmHg, systolic BP >90mmHg, heart rate <120 bpm

Burn Assessment/Interventions

ABCs When the burn occurred, how it occurred, what caused it? LOC, dyspnea, breathing ? Pain assessment Cool water (No ice) Vital signs 1st degree (ointment/simple wound care) IV morphine IV fluids Draw labs: H&H will be artificially inflated, sodium decreased because water has shifted and sodium follows,

Silver Silvadene

ANTIMICROBIAL Bacteria don't like silver

Describe the nursing management and treatment of wound care of open wounds during the emergent phase

Asses vitals-may tell us if hypovolemic shock is occurring Assess wound extensively, measure width/length/depth for baseline, record exudate Clean wound to remove any debris or dirt from wound bed Debridement may be necessary Irrigation using normal saline Use aseptic technique and maintain sterility Treat infection (prophylactically) to prepare wound bed for healing, IV antibiotics in emergent phase-transition to oral medication eventually Depending on extent of wound, may need to start IV fluids to prevent hypovolemia or perform blood transfusion Assist physician with staples/sutures If wound is extensive, prepare for surgery (NPO, start IV, witness consent if possible)

Emergent Phase Intervention

Assess fluid needs Begin IV fluid replacement Insert catheter Monitor I and O Administer tetanus toxoid or antitoxin Assess pain and anxiety Place patient in positions that prevent contracture and edema Give nutrition Give O2 as needed Intubate if necessary

Prehospital-Wounds greater than 10% TBSA

Burn center

Eyes, Ears and nose Burns

Burns to the eyes are a concern because they make self-care difficult and may jeopardize future functions. * give pain medication medication to help the patient open his eyes *provide support to the patient on initial look at skin Burns to the ears are susceptible to infection because of poor blood supply to the cartilage *application of silver sulfadiazine cream to help with infection * may offer debridement * vitamins are given to help with skin development * also giving supplemental iron because there is poor blood supply in the cartilage of ear and it may be messed up now due to the significance of the burn

Face and neck burn

Can interfere with respiratory problems Smoke inhalation

Upper airway injury

Caused by thermal injury to upper airway mouth, oropharynx, and/or larynx. s/s redness, blistering, edema

Circumferential chest

Chest is leathery material/eschar Issue: chest expansion/breathing; airway issues; escharotomy needed Risk for infection and fluid shifts

Rehabilitation Phase

Complete healing occurs Engaging in some level of self care two weeks to 7 to 8 months

Rehabilitation phase interventions

Continue counseling and teach patient and caregiver Continue to encourage and assist with self care Discuss reconstructive surgery Prepare for discharge

Nursing wound treatment for a patient sustaining a 2nd degree/partial thickness burn Acute Phase

Continue daily shower and wound care Continue debridement if necessary Assess wound daily and adjust dressing protocols as necessary Observe for complications such as infection (warm to touch, redness, purulent drainage) Use topical antimicrobial creams or silver-impregnated dressings After debrided, a protective, coarse or fine-meshed, greasy-based re-epithalializing karatinocytes to close the open wound bed If blebs form on a facial graft, aspirate fluid with a tuberculin syringe

Describe the difference in nursing management of continuous pain versus treatment pain.

Continuous Background pain: A continuous IV infusion of hydromorphone for steady pain relief. If no IV is present, morphine can be used for slow release pain relief. "Around the clock" analgesics are another option to provide relief for your patient. Lorazepam (Ativan) and midzolam (Versed) are also indicated because they can increase the effects of analgesics. Gabapentin (Neurotin) or pregabalin (Lyrica) can also be used to increase the effects. They can also help reduce the the dose and the side effects. Treatment Induced pain: Premedicate patient with analgesics and anxiolytics either PO or IV before procedures or activities. Fentanyl is a good IV option. Small doses should be given to keep the patient comfortable because getting rid of all pain is difficult. Most patients will report a tolerable discomfort. continuous pain is pain that is present throughout the day and night and treatment-induced pain is pain associated with dressing changes, ambulation, and rehabilitation activities

Chemical Burn

Don't put water on it You may have to deactivate it What kind of substance?

Expected findings for a patient sustaining carbon monoxide poisoning

Dyspnea Headache Tachypnea Confusion Impaired judgment Cyanosis Respiratory depression Prompt treatment is necessary for these patients including removal from source, administer oxygen, possible intubation or vent, and consider hyperbaric O2 therapy

Emergent Phase Medication

Early on IV medication should be given because of its rapid action. IM medications will not be absorbed if the area id edematous, and oral medication will not be absorbed if the burn is sufficient enough to cause slowed GI function -Opioids used: morphine, hydromorphone, fentanyl, oxycodone, methadone -Tolerance may occur with prolonged therapy. It's important to periodically reevaluate the effectiveness -Sedatives and antidepressants are commonly used concurrently with analgesics to help with anxiety, insomnia, and depression -Commonly used sedatives/hypnotics: Ativan, Versed -Commonly used antidepressants: Zoloft, Celexa -Tetanus Vaccine -Topical creams: Silvadene, Flamazine, Sulfamylon -Lovenox and heparin-- Started when considered "Safe" - Vitamins A,C, and E given to promote wound healing - Zinc and iron given to promote hbg formation and cellular healing

Describe nursing management priorities in the rehabilitation phase

Encourage patient and caregiver participation in care. Teach basic wound care. Provide and plan for pain management and adequate nutrition. Organize home care nursing if necessary. Use water-based creams that will reach to the dermis. Use antihistamines in low doses at bedtime in case of itching. Prepare patient for the possibility of reconstructive surgery. Encourage PT and OT. Provide necessary psychosocial support as the patient works through the long recovery process.

Expected findings for a patient sustaining a 2nd degree/partial thickness burn

Fluid filled vesicles that are red, shiny, and wet (if vesicles have ruptured) Moist blebs, blisters Mottled white, pink to cherry-red skin color Hypersensitivity to touch or air Blanching with pressure Severe pain caused by nerve injury Mild to moderate edema

Expected findings for a patient sustaining a 1st degree/superficial burn

For a superficial burn we would expect to see an injury involving the epidermis so the blood supply to the dermis is still intact. With mild to severe erythema, or pink to red color, present but no blistering. The skin will blanch with pressure. The burn is painful, has a tingling sensation and the pain is eased by cooling. The discomfort can last for about 48 hours and the healing process is 3-6 days long. No scarring should occur and skin grafts are not required. The most common superficial burn is a sun burn.

Acute Phase interventions

INFECTION RISK Septic Shock risk Continue to replace fluids Wound care: Cleanse wounds with soap and water or normal saline-moistened gauze to gently remove the old antimicrobial agent and any loose necrotic tissue, scabs, or dried blood; During the debridement phase cover the wound with topical antimicrobial creams or silver-impregnated dressings. Grafts if needed Continue to assess oxygen needs Continue to monitor respiratory status assess pain and anxiety Nutrition Ongoing support and counseling Assess needs for antibiotics vitamin A and E are the major vitamin needed

Sore throat intervention for burn patient

If complaining of sore throat- Intubation!!!

TPN

Infection is a risk Putting nutrition into the stomach is shown to be better

Describe nursing management of burned extremities, bowel and bladder management

Keep your patient's perineum as clean and dry as possible after each voiding or bowel movement. In addition to monitoring hourly urine outputs, an indwelling catheter prevents urine contamination of the perineal area. It is important that regular one or twice daily perineal and catheter care is done. Assess need for an indwelling urinary catheter on a daily basis and remove when no longer necessary to avoid development of UTI. If your patient has frequent loos stools, consider the temporary insertion of a fecal diversion device. Patients with major burns may also have occult blood in their stools during the acute phase and it requires close monitoring for bleeding. Work in collaboration with physical therapists to perform range of motion exercises on extremities during dressing changes and throughout the day.Movement facilitates mobilization of the leaked fluid back into the vascular bed. Active and passive exercise of body parts also maintains function, prevents contractors and reassures the patient that movement is still possible.

Manifestations of hyperkalemia include:

Muscle weakness/cramping paralysis dysrhythmias cardiac arrest

Autograft

Name the type of graft described by these transplants: • From one site to another on the same person

Describe Acute phase nursing activities related to Excision and Grafting

Removal of necrotic tissue followed by graft application increases chances of wound healing and survival in burn patients This process usually takes place on incident day 1 or 2 (considered the "emergent phase") in the OR. Eschar is removed down to the subcutaneous tissue or fascia (depending on level of injury). Blood loss can occur, so topical epinephrine or thrombin is applied, along with injections of saline and epinephrine. Tourniquets or new fibrin sealants (Artiss) are used in more severe cases. After eschar is removed and blood loss is controlled, skin grafts are applied. Autographs (patient's own skin) are preferred. Grafts are attached via fibrin sealants, staples, or sutures. Allografts can be applied before the autographs to test the patient's acceptability to the grafts. Nursing goals are to promote rapid, moist wound healing and prevent and treat pain and infections.

Describe nursing assessment and treatment of smoke inhalation:

Smoke and inhalation injuries occur from breathing hot air or noxious chemicals can cause damage to the respiratory tract. Due to the facts that smoke inhalation injuries are a major predictor of mortality rate in burn patients, rapid assessment is critical. A careful assessment of the patients face, nasal hairs, whether or not they are hoarse, if they have pain when swallowing, darkened membranes, carbonaceous sputum, a history of being burned in an enclosed space, and any clothing burns around the neck and chest should be done. After assessing airway, breathing and circulation, the patient should be put on 100% humidified O2. The nurse should anticipate endotracheal intubation and mechanical ventilation with significant inhalation injuries. Vital and level of consciousness should be monitored as well as O2 saturation and heart rhythm. Establish IV access with two large-bore catheters if burn is > 15% TBSA. Elevate burned limbs to prevent edema and begin fluid replacement. A catheter should be inserted if burn is >15% TBSA. Administer IV analgesics and assess its effectiveness frequently. Burns should be covered with dry dressing or clean sheet. Assess the patient for other associated injures. Lastly, monitor patient's urine output.

May need what vaccination

Tetanus shot

What types of vaccines are commonly considered for wounds and/or bites would be given by the ED nurse?

Tetanus vaccine Rabies vaccine

Describe nursing management related to Sodium and Potassium in the acute phase

The acute phase of burns starts with the mobilization of ECF and subsequent diuresis and concludes when partial thickness wounds are healed or full-thickness wounds are covered by skin grafts During this phase hyponatremia can occur as a result of excessive GI suction, diarrhea and an increase in fluid intake (even water intoxication). Hypernatremia can also develop during this pause because of excess fluid resuscitation with hypertonic solutions or as a result of tube feedings Hyperkalemia can occur in burn patients with subsequent renal failure, adrenocortical insufficiency or deep muscle injury in which large amounts of potassium leave damaged muscle cells Hypokalemia is a result of excess vomiting, diarrhea, excessive GI suctioning or fluid replacement without potassium supplementation.

Deep Partial Thickness Burn

The structures involved in a 2nd degree partial thickness burn are the epidermis and the top layers of the dermis. Epidermis and dermis involved Second degree burn

Full Thickness Burn

Third degree burn A burn in which all the layers of the skin are damaged. There are usually areas that are charred black or areas that are dry and white. Skin graft needed

Assessment of Burn

WHEN did the burn occur This is a critical question to ask

What physical findings would be related to an electrical burn?

Worse than thermal burn Assume worse than it actually looks because it can be very deep; inside can be severely damaged

escharotomy

a surgical procedure that involves making an incision through the hardened burn eschar, allowing the burn and chest to expand and move with the PT's respiratory movements.

Manifestations of hyponatremia include

weakness dizziness confusion muscle cramps fatigue headache tachycardia

What is the rule of nines and how is it calculated?

assesses the percentage of burns on the body using multiples of 9

Metabolic Asphyxiation

hypoxia and death when carboxyhemoglobin blood levels are greater than 20% Carbon monoxide or hydrogen cyanide with causes a lot of deaths

Manifestations of hypokalemia include

fatigue muscle weakness leg cramps cardiac dysrhythmias paresthesias decreased reflexes

Emergent Phase

first stage of the burn process that is characterized by a catecholamine release and pain mediated reaction. first 72 hours Primary concern is hypovolemic shock and edema

The Parkland Formula

• 4mL x Weight (kg) x TBSA (% burned rule of 9's) = total mL in 24 hours • The first 1/2 is given in the first 8 hours (8 hr clock begins from the time of the burn!). • The last 1/2 is given over the next 16 hours. • Important! When replacing fluid, you must consider what time the burn occurred and the current time. The first half of the volume must be given over the remaining time left of the first 8 hours. For example, if the burn was 1 hour ago, the total volume for the first 8 hours must be infused over the remaining 7 hours MINUS the amount of fluid given prior to arrival. So to calculate the rate the nurse divides by 7 not 8)