ch 62 final

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 The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.

A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?

2 to 5 days after surgery

Parkland formula

4mg/ kg of body weight, and first half within the first 8 hours sencond half in last 16 hrs

homograft (allograft)

: a graft transferred from one human (living or cadaveric) to another human

fasciotomy

: an incision made through the fascia to release constriction of underlying muscle

Burn types

A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client?

Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level.

Pathophysiologic changes with with severe burns:

A superficial burn will cause edema to form within 4 hours, whereas a deeper burn will continue to form edema up to 18 hours post-injury.In burns greater than 30% TBSA, inflammatory mediators stimulate local and systemic reactions resulting in extensive shift of intravascular fluid, electrolytes, and proteins into the surrounding interstitium For patients in the emergent/resuscitative phase, nurses should do a primary survey and monitor circulation. As the taut, burned tissue becomes unyielding to the edema underneath its surface, it begins to act like a tourniquet, especially if the burn is circumferential. As edema increases, pressure on small blood vessels in the distal extremities causes an obstruction of blood flow and consequent tissue ischemia and compartment syndrome.

Potential problems of partial-thickness and full-thickness burns

A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

ABA Formula in Burn Treatment

Administer 2ml/kg/%TBSA for thermal and chemical burns Administer 4ml/kg/%TBSA for Electrical burns Formula applies for 2,3,4th degree burns >20%

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member?

Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Patients are not placed on a calorie restriction during recovery and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

Temperature changes in burn paitents:

Patients with burn injuries may, therefore, exhibit low body temperatures in the early hours after injury. found that hypothermia (i.e., core temperature less than 36.5°C [97.7°F]), on admission of patients to the hospital was an independent predictor of mortality. After the initial few hours, persistent increases in baseline core temperature ensues as part of the physiologic and metabolic response to a burn injury

ABCDE's of the Primary Survey

Airway: Breathing: Circulation Deficits Exposure

Graft types

Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?

Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, base-bicarbonate deficit, and elevated hematocrit. PT does not typically decrease.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?

As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

Inhalation injury:

Can be thermal or Chemical, Upper airway damage(above glottis) can be thermal or chemical Lower airway(below glottis) usually chemical bronchoscopy is the golden diagnostic test, due to inital CHEST XR SEEMING NORMAL.

massive cell destruction may cause

Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

What occurs w/electrolyte immediately after burn?

Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. Serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss or may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space. hematocrit may be elevated due to plasma loss. Abnormalities in coagulation, including a decrease in platelets (thrombocytopenia) and prolonged clotting and prothrombin times, also occur.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement.

normal hematocrit levels

Male: 42-52% Female: 37-47%

Types of debridement

Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue.

Rule of 9's

Most common method Each arm= 9%, Anterior leg=9%, Posterior leg=9% Head=9%, Back=18% Chest=18%, Perineum=1%

Lund and Browder

Most precise method recognizes the percentage of surface area of various anatomic parts, especially the head and legs, as it relates to the age of the patient. By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by each body part, clinicians can obtain a reliable estimate of TBSA burned. The initial evaluation is made on arrival of the patient to the hospital and should be revised within the first 72 hours, because demarcation of the wound and its depth present themselves more clearly by this time

xenograft (heterograft)

transplantation (dermis only) from a foreign donor (usually a pig) and transferred to a human

Curling's ulcer

ulceration of gastric or duodenal tissue as a result of burn or trauma.

Irrigation of chemical injury should begin when?

Should begin immediately and be continuous.

the three major antimicrobials used to treat burns.?

Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?

Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.

Methods of assessing TBSA

The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%,whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.

MX for burns

The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?

The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.

detrimental effects of radiation injuries:

Thermal effect. DNA DAMAGE.

Hemodilution

an increase in blood plasma, resulting in a dilution of the blood's cellular contents

Medical management for severe pulmonary injury:

bronchial suctioning may be necessary and the use of mucolytics

Hematocrit

percentage of blood volume occupied by red blood cells

Nutrition requirements

protein requirements of 1.5 to 2 g/kg/day. Carbohydrates are the most important energy source and should account for 55% to 60% of nutrition delivery to decrease protein catabolism (Abdullahi & Jeschke, 2014). Fat, although a required nutrient, should be provided in more limited quantities. When the oral route is used, high-protein, high-calorie meals and supplements are given. Dietary consultations are useful in helping patients meet their nutritional needs. Daily calorie counts aid in assessing the adequacy of nutritional intake.

methods used to estimate TBSA:

rule of nines, the Lund and Browder method, and the palmer method

contracture

shrinkage of burn scar through collagen maturation

Which of the following topical burn preparations act as wick for sodium and potassium?

silver nitrate , stains, does NOT penetrate eschar

Indicators of possible pulmonary damage include:

singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

Three Phases of Burn Care

1. Resuscitative/Emergent phase (fluids, 1st 48 hrs, greatest risk shock, 100 L hour most critical phase of shock state) 2. Acute phase (48 hrs to wound closure) once balanced, diuresis 3. Rehabilitative phase (closure to back to normal) acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound dbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

Medical management for mild pulmonary i njury:

100% oxygen and encouragement of coughing to remove secretions.

Nikolsky sign

Diagnostic sign whereby the superficial epithelium separates easily from the basal layer on exertion of firm, sliding manual pressure with the fingers

Concept Mastery Alert

For patients in the emergent/resuscitative phase, nurses should do a primary survey and monitor circulation. As the taut, burned tissue becomes unyielding to the edema underneath its surface, it begins to act like a tourniquet, especially if the burn is circumferential. As edema increases, pressure on small blood vessels in the distal extremities causes an obstruction of blood flow and consequent tissue ischemia and compartment syndrome.

Palmer method

In patients with scattered burns, the Palmer method may be used to estimate the extent of the burns. The size of the patient's hand, including the fingers, is approximately 1% of that patient's TBSA

The following factors are considered in determining depth of a burn : or

The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The patients preinjury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing?

When occlusive dressings are applied, precautions are taken to prevent two body surfaces from touching, such as fingers or toes, ear and scalp, the areas under the breasts, any point of flexion, or between the genital folds.

During dressing changes:

Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn't use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.

Biobrane

______ is a biosynthtic dressing made of a silicone film in wich a nylon fabric is partially embedded.As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. There is no need to reinforce the Biobrane nor to remove it and apply a new dressing. There is not likely any need to notify the physician for further orders

full thickness 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. Also called a third-degree burn.

partial thickness burn

a burn involving the epidermis and dermis that usually involves blisters; commonly called a second-degree burn

Carboxyhemoglobin

a compound of carbon monoxide and hemoglobin, formed in the blood with exposure to carbon monoxide

escharotomy

a linear excision made through eschar to release constriction of underlying tissue

Collagen

a protein present in skin, tendon, bone, cartilage, and connective tissue

eschar:

devitalized tissue resulting from a burn or wound

When is fluid resuscitation indicated?

fluid resuscitation is initiated in burns greater than 20% TBSA to maintain adequate organ perfusion. Baseline weight and laboratory test results are obtained, and these parameters must be monitored closely in the immediate post-burn (resuscitation) period. Both under-resuscitation and over-resuscitation with IV fluids are associated with poor outcomes. Shock, ischemic complications, and multiple organ dysfunction syndrome (MODS) occur with under-resuscitation (see Chapter 14), and heart failure and pulmonary edema occur with over-resuscitation

Secondary survey

focuses on obtaining a history, the completion of the total body system assessment, initial fluid resuscitation, and provision of psychosocial support of the conscious patient

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn?

hyperglycemia. When the adrenal cortex is stimulated, it releases glucocorticoids , which cause hyperglycemia. Sodium retention leads to peripheral edema. There is a decreased urine output, initially.

The greatest volume of fluid loss occurs

in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours. Edema forms rapidly after a burn injury. A superficial burn will cause edema to form within 4 hours, whereas a deeper burn will continue to form edema up to 18 hours post-injury. This is caused by increased perfusion to the injured area in the presence of increased capillary permeability and reflects the amount of microvascular and lymphatic damage to the tissue. In burns greater than 30% TBSA, inflammatory mediators stimulate local and systemic reactions resulting in extensive shift of intravascular fluid, electrolytes, and proteins into the surrounding interstitium

Hoarseness is indicative of

injury to the respiratory system and could indicate the need for immediate intubation.