Integumentary: Saunders NCLEX Review, Burn Injuries

hemolysis of RBC

initially Hct may be elevated (hemoconcentration); once fluid balance is restored anemia may be apparent Myoglobin in urine is released which can cause Rhabdomylosis and ATN ( acute tubular necrosis) (Acute renal failure)

513.The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels

4.Elevated hematocrit levels Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (select all that apply) A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. C. Urine specific gravity is 1.025. D. Mean arterial pressure is 54 mm Hg. E. Systolic blood pressure is 88 mm Hg.

A, B, C A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. C. Urine specific gravity is 1.025. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be at least 0.5 to 1 mL/kg/hr. Cardiac factors include a mean arterial pressure (MAP) > 65 mm Hg, systolic blood pressure (BP) > 90 mm Hg, heart rate < 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030.

The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Administer 100% humidified oxygen. B. Teach the patient deep breathing exercises. C. Encourage the patient to express his feelings. D. Assist the patient to a high Fowler's position.

A. Administer 100% humidified oxygen. Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.

The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? A. Skin is hard with a dry, waxy white appearance. B. Skin is shiny and red with clear, fluid-filled blisters. C. Skin is red and blanches when slight pressure is applied. D. Skin is leathery with visible muscles, tendons, and bones.

B. Skin is shiny and red with clear, fluid-filled blisters. Deep partial thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

Which patient should the nurse prepare to transfer to a regional burn center? A. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% B. A 39-year-old patient with a partial-thickness burn to the right upper arm C. A 53-year-old patient with a chemical burn to the anterior chest and neck D. A 42-year-old patient who is scheduled for skin grafting of a burn wound

C. A 53-year-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

Treatment

Emergency Treatment Stop the burning ABCs *consider C-spine and internal injuries Conserve body heat- lose own body heat from fluid loss Minimize wound contamination- sterile sheets, bedding Remove jewelry/constricting garments Transport quickly Keep NPO - secondary may need surgery History of accident and medical history

Fluid Resuscitation

First 24 hours Ringer's Lactate is used Eg. Parkland formula: 4ml/kg/%TBSA ½ of the calculated amount is given over the first 8 hours since injury The rest is given over the next 16 hours Eg. Pt. weighs 50 kg., has 50% TBSA burns. Injury was @ 0900h. And the IV was started at 1000h. Calculate the total volume for the 24 hours At what time should the first 5000 ml be finished? 1st 8 hours 0900-1700 4X50X50 =10,000ml -1/2 in first 8hr = 5,000ml - 7 hours left run @ 714 ml/hr - 1700-0900 16 hrs run @ 312 ml/hr

Ineffective tissue perfusion

-Assess pulses -Elevate extremities -Assist with escharotomy and fasciotomy

Eschar

(sloughing layer of necrotic tissue, collagen and protein exudate that coagulates into a hard crust) + edema →tight constricting band that prevents airway/chest expansion

Symptoms of Smoke Inhalation

- Presence of soot around mouth and nose and in sputum (carbonaceous sputum) -Tachycardia -Stridor -Wheezing -Hoarseness -Hypoexmia -Facial burns -Difficulty swallowing -Singed nasal hairs -Intercostal/suprasternal retractions

Pt @ home 10 days after burn of L hand and arm, partial thickness burn what are priorities

- assessment - health teaching - assessing for infection - fever, pus, smell - pain : medication working, ADL, Sleep - wound healing: protein + Vit C ( componant of making collogen) - increased calories - hungry - nausea - stress ulcer

Rule of nine for adults perineal

-1%

In Suspected Inhalation Injury What is the Recommended % of 02 and Mode of Delivery?

-100% HUMIDIFIED O2 by NON-Rebreathing facemask or endotracheal tube.

Rule of nines for adults legs

-18% EACH -9% anterior -9% posterior

Rule of nines for adults back and chest

-18% each

Rule of nines for adults face

-9% -4.5% anterior -4.5% posterior

Rule of nines for adults arms

-9% EACH -4.5% anterior -4.5% posterior

Objective Physical Findings During the Emergent Phase of Burn Injury

-Airway & Breathing (upper burns) and circulation -Pain (Lower burns) -Tachycardia -Amount of fluid coming out of the body -Mouth and nose and in sputum (inhalation) -Hoarse voice -Notice and document circumferential burns

Impaired Skin Integrity

-Assess skin for warmth, redness, color, drainage -Use Norton or Braden scale for risk assessment -Position the child on the opposite side of the skin impairment to avoid further skin breakdown -Proper nutrition -Wound and Ostomy care

Silver Sulfadiazine (Silvadene)

-Bactericidal -FOR BURNS -Apply two times a day -Cover with occlusive dressing -DON'T USE IN CHILDREN WITH SULFA ALLERGY -DON'T use on face or a child younger than two months -May cause transient neutropenia

What are fluid resuscitation requirements?

-Body weight in kg -The % of TBSA burned -Patients age - 4mL x wt (kg) x TBSA (%)

Partial Thickness

-Epidermis and dermis -Heal within two weeks with minimal scarring

Goals with patients at risk for skin integrity

-Explain to the client that they will be turned and how often -Position proper body alignment -Use speciality beds and mattresses as need -Document skin status every shift -Remove moisture -Apply protective barriers

What is the parkland formula?

-How much LR to give in the first 24 hours -4mL x wt (kg) x TBSA (%) = Volume (mL) -Half is given in the FIRST 8 hours -Ex) 2,400mL/2 = 1,200 for FIRST 8 hours - Remaining volume divided into HALF again for second and third 8 hours - Ex) 1,200 (remaining)/2 = 600 mL Second & 3rd 8 Hours (16 hours total)

Excoriation

-Loss of superficial layers of the skin -caused by urea, gastric tube drainage, digestive enzymes in feces

Ineffective airway clearance for burns

-Monitor SpO2 every hour -Assess RR -Auscultate breath sounds q4h -Cough and deep breathe every hour awake -Turn every 2 hours -Elevate HOB -Schedule activities to avoid fatigue

Risk for hypothermia for burns

-Monitor rectal/core temp every hour -Monitor for shivering -For temps less than 98.6 institute rewarming measure

Anticipated Therapeutic Outcome of Escharotomy/Fasciotomy

-Relieve pressure -Restore circulation

Full thickness

-Significant damage -Epidermis, dermis, hypodermis -Extensive scarring -Significant time needed to heal

Deep Partial-Thickness

-Take longer to heal -May scar -Resulting in nail hair and sebaceous gland function

The infants epidermis is

-Thinner than the adults

Maceration

-Tissue softened by prolonged wetting and soaking

What Physical Objective Finding Would Best Reflect Adequate Fluid Resuscitation During the Emergent Phase of Burn Injury?

-Urine output

516.The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1.Vital signs 2.Urine output 3.Mental status 4.Peripheral pulse

2.Urine output Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 to 50mL.

509. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1.18% 2.24% 3.36% 4.48%

3.36% Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.

classification of burns

Burn Depth Partial thickness - superficial Partial thickness - deep- takes first layer of dermis off Full thickness Extent of Body Surface Area Injured TBSA

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change? A. Morphine sulfate B. Sertraline (Zoloft) C. Zolpidem (Ambien) D. Enoxaparin (Lovenox)

A. Morphine sulfate Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.

full thickness burn

Apperance: deep, res, black white and brown Dry surface, edema, fat exposed, tissue disrupted Sensation: little pain, anesthetic course: 2-3 wks to heal requires removal of eschar and skin grafting

Partial thickness burn

Apperance: large thick walled blisters covering extensive areas Edema: molted red base; broken epidermia, wet, shiny weeping surface Sensation: painful, sensative cold Course: heals in 10-14 deep burn takes 21-28

superficial burn

Apperance: mild to severe erythemia, skin blanches with pressure - skin dry -small, thin - walled blisters Sensation: painful, hyperesthetic, tingling, pain eased by cooling Course : discomfort last for about 48hrs

Breathing

Breathing pattern, ABGs, O2 sat, supplemental oxygen airway obstruction - inhalation - secondary edema

Burn Shock

Compensation with intense peripheral vasoconstriction for 1-2 hours BP- decrease HR- increase Urine output- decrease When compensatory mechanisms fail S&S of hypovolemic shock will appear with CO ↓ 30-50%

Psychosocial implications

Pain Depression- milieu therapy Self-image Self-worth Risk for suicide Role in the family / at work Coping Distrust Getting on with life...

incidence of burns

~ 200,000 burns/year reported in Canada 5% require hospitalization In Ontario burns account for 1000 hospitalizations/year and 10,800 hospital days Mortality rate ~90% if >60 years of age, TBSA>40%, and inhalation injury

wound debridement

Removes devitalized and contaminated tissue Exposes granulation tissue Promotes healing and decreases infection although debrided wounds are at greater risk of infection Natural (dead tissue separates spontaneously) Mechanical (surgical scissors, wet-to-dry dressings, topical enzymes) Surgical (early and aggressive surgical wound closure has lowered incidence of septic shock)

GI symptoms from acute phase

↓blood flow → ↓peristalsis → paralytic ileus Stress response → ↑ catecholamines → ↓ mucus and ↑ gastric acid = Curling's Ulcer (a form of stress ulcer with diffuse lesions) Assessment ______________ Treatment: NGT to suction (decompression), Zantac (Ranitidine)

EXTENT OF BODY SURFACE AREA INJURED

Rule of Nines - add 9 for each area of burn Lund and Browder- % of burn Palm Method Approx. 1-3% per "palm"

Immune system

Skin barrier is destroyed Decreased effectiveness of immune system 70% of those with burns die if they develop sepsis

Airway

Smoke Inhalation (check for soot on skin/clothes and carbonaceous sputum) Assess for respiratory distress, ↓pO2, altered LOC Treated with oxygen, bronchodilators CO poisoning Oxygen is displaced from HGB- CO2 higher afinity for HGB Cherry red lips and skin may not be present Treated with 100% oxygen, positioning, DB&C - bright red skin to much CO2 Airway Obstruction 2°edema, circumferential burns Pneumonia ARDS ( acute respiratory distress syndrome) (2-5 days post burn with 50% mortality)

Severity of burn determined by:

TBSA injured Burn depth Location of burns Age Concommitant(another injury on top of burn) injury Past health history

causes of burns

Thermal - heat Chemical- laundry detergent, alkaline burn worse then acid Electrical- lightning strike- coterizes bld flow

Acute phase of the burn

Begins with mobilization of fluid (= diuresis) and ends when burned area is completely covered or healed Highest risk of infection in this stage Can last 48 hours, weeks or months

more then 8% burn

need fluid replacement

510. The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue

1.Return of distal pulses Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through a vascularescharto subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

518.The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position

3.Immobilization of the affected leg Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Options 1, 2, and 4 are incorrect.

517. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1.Using sterile sheets and linens 2.Performing strict hand washing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

3.Wearing gloves and a gown only when giving direct care to the client Rationale: Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.

512.A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1.Restrict fluids. 2.Assess for airway patency. 3.Administer oxygen as prescribed. 4.Place a cooling blanket on the client. 5.Elevate extremities if no fractures are present. 6.Prepare to give oral pain medication as prescribed.

2, 3, 5 2.Assess for airway patency. 3.Administer oxygen as prescribed. 5.Elevate extremities if no fractures are present. Rationale: The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock. The client is kept warm and placed on NPO status because of the altered gastrointestinal function that occurs as a result of a burn injury.

Phases of burn management

Emergent (Resuscitative) Phase Acute Phase Rehabilitation Phase

Autograft - permanent coverage

From patient- Cultured

a sun burn is what type of burn

primary - increases risk of melanoma

515.A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1.100% oxygen via an aerosol mask 2.Oxygen via nasal cannula at 6L/minute 3.Oxygen via nasal cannula at 15L/minute 4.100% oxygen via a tight-fitting, non rebreather face mask

4.100% oxygen via a tight-fitting, non rebreather face mask Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting non-rebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Options 1, 2, and 3 are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion.

fasciotomy

remove pressure form eschar ( compartment syndrome) decrease pressure

511. A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mmHg, a pulse rate of 110 beats/minute, and a urine output of 20mL over the past hour. The nurse reports the findings to the healthcare provider (HCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains dextrose in water

3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. Blood replacement is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because it would not replace needed fluid. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Dextrose in water is an isotonic solution, and an isotonic solution maintains fluid balance. This type of solution may be administered after the first 24 hours following the burn injury, depending on the client's physiological needs.

Synthetic & Biosynthetic grafting

Integra synthetic skin Alloderm product

Nutrition

Hypermetabolic state Caloric needs Protein requirement is high for healing If caloric needs are not met a state of negative nitrogen balance exists leading to Delayed healing Infection Wasting of body mass Death Oral or enteral feeds, TPN if GI tract not functional Transient ↑ blood sugar

Major complications

Hypertrophic scarring Occurs 2° to ↑ vascularity, ↑ fibroblasts, collagen deposits, edema Scar formation occurs over ~ 2 years Melanocytes do not regenerate well...in deep burns skin color usually does not return Contracture formation PT, OT, NUTRITION

Integument tx

Initial cleansing with tepid (cool/cold) N/S removes debris and removes surface bacteria Open method: topical antibiotic applied without a dressing Closed method: sterile dressing (wounds heal best in a moist environment) Flamazine (broad spectrum) Polysporin Tetanus toxoid

Circulation after burn

MONITOR TISSUE PERFUSION CLOSELY Additional fluid: FFP, colloids once capillary permeability is restored By 48 hours capillaries begin to seal and fluid will return from third spaces to the vascular space→ watch for fluid volume overload

Circulation

Massive fluid shift from plasma to interstitium- interstitium exposed to air- wheep Sodium and protein move out of the vascular bed- lost serum Potassium increases due to damaged cells- K is intracellular end up in pt blood Wound allows evaporation to occur 4-15x normal rate → BURN SHOCK

mild, moderate and major burn TSBA

Minor burn <15% partial thickness/<2% full thickness Moderate burn 15-25% partial thickness/ < 10% full thickness Major burn > 25% partial thickness/ > 10% full thickness

Emergent resuscitative phase

Begins with fluid loss and edema formation at time of burn *greatest threat is hypovolemic shock- BP decreases, HR increases, U/O decreased Continues until fluid mobilization and diuresis occurs ABCs are the priority Can last 48 hours to several days

Temporary coverage grafting

Allograft (cadaver skin) Xenograft (biological dressing usually pigskin)