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Burns

  1. Survival rate of burns:
    94.8
  2. Males vs Females for Burns
    • 69% males
    • 31% females
  3. Mean age of burns
    32

    (older more often than younger)
  4. Most common ethnicity for burns:
    Caucasian- 58.9%
  5. Most common admission cause from burns:
    Fire/Flame 43%
  6. Average length of stay for burn pt
    8 days
  7. Top 4 Complications of burns:
    • Pneumonia
    • Cellulitis
    • Septicemia
    • Wound Infection
  8. Approximately ___ out of 10 home fire deaths occur in homes without smoke alarms
    4
  9. Most residential fires occuring during the ____
    winter months
  10. Change smoke alarm batteries with every ____
    time change (2x a year)
  11. Alcohol use contributes to an estimated ___% of residential fire deaths
    40%
  12. Gerontological Considerations r/t burns:
    Diminished mobility, strength, coordination, sensation, visual acuity, and declining memory

    (older adults have thinner skin, which can affect the depth of the burn and ability to heal....Decreased CO makes for fine line between fluid resuscitation and fluid overload)

    • Majority of burns with gerontology pts occur in the home from:
    • Carelessness from smoking, cooking, or tub scalds
  13. Biggest Complication of Burns:
    Long hospital stays
  14. Strongest predictors of mortality:
    % of TBSA burned

    Presence of inhalation injury (strongest that leads to death)

    Increased age (may not be able to fight as well as younger pt)
  15. Goals of burn care:
    Prevention and treatment of shock

    Alleviation of pain

    Control of bacterial growth on the burn wound and in the body

    Conversion of an open wound to a closed wound

    Preservation of body function and appearance

    Healing within a minimal length of time

    Preservation of mental and emotional equilibrium

    Return of client to the social and work environment
  16. ____ is our first line of defense against infection
    Skin!!! (insulates and protects)
  17. Classifications of Burn Injuries
    • 1st- epiderma
    • 2nd- partial-thickness
    • 3rd- full-thickness
    • 4th- full-thickness that includes fat, fascia, muscle, and/or bone and fat
  18. Burn that would be categorized as a bad sunburn...often blisters
    2nd degree
  19. ____ degree burns are painless because there have been damaged nerves
    3rd and 4th
  20. Degree of Burn: Dry, minor blisters, erythema
    1st degree
  21. Degree of Burn: Moist, Reddened with broken blisters
    2nd degree
  22. Degree of Burn: Dry, pale, white, red brown, leathery, or charred...coagulated vessels may be visible, edema
    3rd Degree burn
  23. Degree of Burn: Dry, charred
    4th degree
  24. Type of Causative Agents:
    • Thermal Burns (flame- house, burning car, clothes catch fire)
    • Chemical Burns
    • Electrical Burns
  25. Major burn is classified by:
    2nd degree burns > 25% of TBSA
  26. Minor burns are classified by:
    Less than 15% of the body
  27. Moderate burns are classified by:
    15-25% of the body
  28. Chemical burns could be from:
    Alkalis, Acids, Organic Compounds
  29. Severity of chemical burns is related to:
    • Agent
    • Concentration
    • Volume
    • Duration of Contact
    • Mechanism of Action of the Agent
  30. Treatment of Chemical Burns:
    Universal precaution (gloves, gown, and eye protection prior to contact with patient)

    Remove all clothing

    Brush off any remaining agent

    Irrigate with copious amounts of water to make sure all chemical is off (until pts pain is relieved or transferred to a burn center)

    HYDROTHERAPY is a huge concept for nursing care in chemical burns!!!
  31. Grand Masquerader
    Electrical Injury
  32. Findings that suggest Electrical Injury
    Loss of consciousness

    Paralysis or mummified extremity

    Loss of peripheral pulse

    Flexor surface burns

    Myglobinuria (released by damaged muscles...will clot kindneys)

    Serum CK above 1000 IU

    (pt may lose consciousness....it may be hard to tell that the pt had an electrical injury)
  33. Electrical injury effect is determined by:
    Pathway of the current (entry wounds charred and leathery, exit wounds "blow out")

    Duration of contact

    Area of contact

    Resistance of the body (Bone = least damaged)...tissues, nerves, muscle
  34. Interventions of thermal burns:
    Assess for inhalation therapy (smoke inhalation)

    Start Fluid Replacement if >15% TBSA burned
  35. Interventions for Inhalation burns:
    • (Blood gas with carboxyhemoglobin...carbonmonoxide poisening)
    • Chest X-Ray
  36. Interventions for Chemical Burns
    • Assess ABGs
    • Decontaminate (Flush and Hydrate with FLUIDS!!!)
  37. Interventions for Electrical burns:
    Check pulses distal to burn

    Monitor for myglobinemia

    Be prepared to administer mannitol to maintain U/O (osmotic diuretic to help pull fluid back and flush kidneys out)

    Sodium Bicarb to alkalinize the urine
  38. How to determine severity of the burn:
    % of total body surface area (TBSA)

    Depth of burn

    Anatomical location of burn

    Age

    Medical hx

    Presence of concomitant injury

    Presence of inhalation injury
  39. Rule of Nines: Face
    4.5%
  40. Rule of Nines: back of head
    4.5%
  41. Rule of Nines: Chest
    9%
  42. Rule of Nines: Back
    9%
  43. Rule of Nines: Front of arm
    4.5%
  44. Rule of Nines: Total arm
    9%
  45. Rule of Nines: Abdomen
    9%
  46. Rule of Nines: Lower back/butt
    9%
  47. Rule of Nines: Perineum
    1%
  48. Rule of Nines: Front of leg
    9%
  49. Rule of Nines: back of legs
    9%
  50. How does the rule of nines differ for kids
    Kids have bigger heads than bodies so their heads count more
  51. Measure scattered burns by:
    using the palm of pt's hand including fingers....1% of TBSA
  52. When to assess TBSA Burned
    On admission

    (reassessment on day 2-3 because the wound and it's depth will be more clear)
  53. Three Burn Zones
    Zone of Coagulation (cellular death, area of most damage)

    Zone of Stasis (compromised blood supply, inflammation, injury)

    Zone of Hyperemia (least damage)
  54. Zone characterized by cellular death (most damage)
    Zone of Coagulation
  55. Zone characterized of compromised blood supply, inflammation, and injury
    Zone of Stasis
  56. Zone characterized with least amount of damage
    Zone of Hyperemia
  57. Image Upload 2
    Burn Zones
  58. Burns will swell, causing:
    Compression (airway, circulation, and blood flow)
  59. Burns effect ____ system in the body
    EVERY!!!
  60. Effects on Respiratory System from Burns:
    Direct airway injury

    Inhalation injury (breathing smoke)

    Carbon monoxide poisoning (fallen asleep, decreased LOC)

    Alveolar Damage

    Pulmonary Edema

    Decreased oxygen diffusion
  61. Effects on Cardiovascular System from burns:
    Fluid volume deficit (from interstitial spaces outward, causing the things below)

    Decrease mean BP

    Decrease CO

    Hypovolemic Shock

    Decrease myocardial contractility (improves 24-48 hours post injury)

    Electrical burns (EKG changes, MI, Ventricular fibrillation, and cardiac arrest)
  62. Effects on Renal System from Burns
    Decreased Renal Perfusion (oliguria)

    Acute Renal Injury (electrical shock...must find way to flush everything out!!!)

    May see Red/Brown urine (be very concerned and hydrate patient!!!)

    ***any time we have compromised cardiac, it will compromise our kidneys bc blood will be shunted toward the brain and important organs
  63. Effects on GI system from Burns:
    Ileus (Place NG tube!!!)

    Stress Ulcer Formation (protonix)

    Translocation of bacteria

    Abdominal compartment syndrome (everything gets too tight and things cannot expand and move like they should)
  64. Effects on the Neuroendocrine System from Burns
    Increased Metabolic Rate (increased caloric needs-- NG TUBE!!!!)

    Increased Cortisol Levels (insulin resistance and hyperglycemia...someone who is not diabetic may need insulin during this time...monitor sugars carefully)
  65. Effects on the Immune and Musculoskeletal and Integumentary from burns
    Immunosuppression (sets pt up for infection)

    Contractures

    Inability to regulate body temperature (from loss of skin)...hypothermia
  66. From the onset of injury to completion of fluid resucitation
    Emergent Phase (from the second the EMT gets there)
  67. Management Principles for the Emergent phase of burns:
    Stop burning process

    Universal Precautions

    Fluid resuscitation

    Vital Signs

    Insertion of NG tube

    Insertion of Urinary Cath

    Assessment of Extremity Perfusion

    Continues Ventilatory Assessment

    Pain Management

    Pain management

    Psychosocial Assessment
  68. Ways to Stop the Burning Process
    Extinguish Flames (stop, drop, roll...Smother with blanket)

    Cool the Burn (water briefly, never apply ice, never use cold dressings for longer than several minutes)

    Remove restrictive objects (Ring, Watch)

    Cover the Wound (clean, dry cloth)

    Irrigate chemical burns
  69. Priorities for Burn Pt
    Airway (cervical spine protection)

    Breathing/Ventilation

    Circulation with hemorrhage control (MVC)

    • Disability (neuro deficit/ pt fall)
    • Defibrillate (if pt in ventricular fibb from electrical fire)

    Exposure (completely undress pt but maintain temperature)
  70. Nursing assessment/interventions of breathing/ventilation in burn pt:
    Assess adequace of rate/depth

    Listen to verify breath sounds in each lung

    High flow Oxygen at 15L (100%) with a non-rebreathing mask
  71. Leading cause of death in burn pt in first 24 hours
    Inhalation injury
  72. 3 stages of inhalation injury:
    1. Acute pulmonary insufficiency (36 hours)

    2. Pulmonary edema occurs between 6-72 hours after injury

    3. Bronchopneumonia occurs 3-10 days after injury
  73. Inhalation injury occuring in first 36 hours
    Acute pulmonary insufficiency
  74. Inhalation injury occuring between 6-72 hours after injury
    Pulmonary Edema
  75. Inhalation injury occuring 3-10 days after burn injury
    Bronchopneumonia
  76. Findings suggestive of Inhalation Injury in Burn pt
    • Occured in confined area
    • Singed nasal hairs
    • Burns of oral or pharyngeal mucous membranes
    • Burns in perioral area of the neck
    • Carbonaceous sputum
    • Change in voice (hoarsness)
    • Stridor
    • Dyspnea
    • Tachypnea
  77. Nursing interventions when carbon monoxide toxicity is suspected:
    100% high-flow Ox (non-rebreathing)

    Carbon Monoxide has half life of 4 hours when pts brethe room air (45 min if pt breathing 100% ox)

    Serial ABGs
  78. Clinical presentation of 10% carbon monoxide tox:
    no sx
  79. Clinical presentation of 20% carbon monoxide tox:
    H/A, vomiting, dyspnea on exertion
  80. Clinical presentation of 30% carbon monoxide tox:
    Confusion, Lethargy, Changes on EKG
  81. Clinical presentation of 40-60% carbon monoxide tox:
    Coma
  82. Clinical presentation of >60% carbon monoxide tox:
    Death
  83. Finding typically associated with high carboxyhemoglobin level:
    Cherry Red Skin! (Ox Sat is usually normal)
  84. IV nursing interventions for Burn Pt:
    • 2 large bore cath
    • Begin fluid administration
  85. Circulation assessment for Burn Pts
    • BP
    • Pulse
    • Skin Color

    IV- 2 large bore, begin fluids (non burned skin if possible)

    Check for impaired circulation to extremities

    Elevate burned extremities above the level of the heart (to minimize swelling)
  86. If burn pt is not alert, consider possible causes:
    Carbon Monoxide poisoning

    Substance Abuse (alcohol and possibly drugs)

    Hypoxia
  87. Cover burn pt with ___ sheets
    warm, dry

    (maintain pt temp!!!)
  88. Administer ____ medication because IM injections will usually not be well absorbed
    IV pain medication
  89. Burn pts are at high risk for ____ (maintain temp!)
    Hypothermia
  90. Strategies to prevent hypothermia (increases pt risk of wound infection and blood loss)
    Ensure no wet dressings or wet linens on pt

    Use a fluid warmer to infuse fluids

    Maintain a warm room

    Cover pt, including burned area with clean blanket and cover pt head with towel or sheet

    Tuck sheet in under the pt to prevent loss of heat
  91. Labs to assess on burn pt
    • CBC
    • Chemistry with BUN
    • Creatinine Level
    • Urinalysis
    • ABGs with carboxyhemoglobin (for suspected inhalation)
    • ECG 
    • Chest X-ray
    • Glucose in children and diabetics
  92. Fluid and Electrolyte imbalances
    Hyperkalemia (immediately)

    Hypokalemia (with fluid shift)

    Hyponatremia

    Metabolic Acidosis
  93. Interventions for Mild Inhalation Injury
    • High Fowlers Position
    • 100% humidified oxygen by mask
    • May use aerosolized racemic epinephrine
  94. Interventions for Severe Inhalation Injury:
    Intubation

    Adhesive tape does not adhere well to burned skin...ET should be secured with umbilical tape
  95. Most common cause of death in burn pts after 7 days due to loss of mechanical barrier to environment
    Infection
  96. Why are Dx of Infection in burn pts difficult:
    Burn pts have elevated core temps and elevated WBCs
  97. ___ in urine is a sign of infection in burn pts
    Glucose

    (difficult to control blood sugars in diabetics)
  98. Take ____ of burn wounds to assess for infection
    Biopsy
  99. American Burn Association: Sepsis/Infection in Burn Pts
    Temp > 102.2 or < 97.7

    HR > 110

    RR > 25 

    Thrombocytopenia <100,000

    Hyperglycemia (no preexisting diabetes) or insulin resistance

    Enteral feeding intolerance

    Concern for infection if at least 3 of the above!!!
  100. Ways to prevent infection inf burn pts
    wash hands (before touching pt)

    sterile technique with tubes

    sterile gloves for dressings
  101. Burn Center Referral Criteria:
    Partial thickness burns greater than 10% TBSA

    Burns that involve face, hands, feet, genitalia, perineum, major joints

    3rd degree burns in any age group

    Electrical burns, including lightning injury

    Chemical Burns

    Inhalation Injury

    Burn injury in pt with pre-existing conditions

    Any pt with burns and concomitant trauma

    Burned children in hospital without qualified personal

    Burn injury in pts who will require long-term rehab intervention
  102. Stabilization in prep for pt transfer
    100% oxygen

    Two 16 gauge IVs ... make sure well secured

    Begin Fluid Resuscitation

    Keep NPO until transfer

    Insert NG tube >20% TBSA

    Cover with Clean Dry Sheet

    Pain med (IV)

    Tetanus immunization if due

    DOCUMENT
  103. Tetanus prevention:
    Completely preventable by active tetanus immunization. Immunization is thought to provide protection for 10 years.

    Immunizations begin in infancy with the DTaP series of shots. The DTaP vaccine is a "3-in-1" vaccine that protects against diphtheria, pertussis, and tetanus

    Immunity in those age 11 and older. Tdap vaccine should be given once, prior to age 65, as a substitute for Td for those who have not had Tdap. Td boosters are recommended every 10 years starting at age 19.
  104. Effects of SNS on burn pt:
    • Thirst
    • GI Hypomotility
    • Adrenal Stimulation (increased metabolic rate and hepatic stimulations)
  105. Image Upload 4
  106. Fluid of choice for Shock Resuscitation:
    Lactated Ringers
  107. Obtain a ____ weight as early as possible on burn pts in shock
    Dry
  108. U/O, CVP, and PAP should be monitored ____
    Hourly

    (acidosis, hyperkalemia, hyponatremia)
  109. Results from shift of fluid in burn pts...
    Hypovolemia
  110. Shift of fluid vascular space to interstitial spaces
    2nd spacing
  111. Shift of fluid to areas normally having minimal fluid
    3rd spacing

    (blister formation and edema in non-burned areas)
  112. Reasons of Hypovolemia in burn pt
    2nd and 3rd spacing

    Insensible loss by evaporation

    Hemolysis of RBC

    Increased Hct (due to hemo concentration from fluid loss)

    Major shifts in Sodium and Potassium
  113. During Hypovolemic Shock, existing volume is shifted to:
    Vital Organs (Heart, Lungs, Brain)

    Hypoperfusion of other organs (liver, stomach, kidneys)
  114. People most sensitive to fluids:
    • Children
    • Elderly
    • Pt with preexisting cardiac disease
  115. Calculation of Fluids (Parkland formula) for adults:
    Lactated Ringers (4ml) * Body Wt in KG * %TBSA
  116. First 8 hours of burn, give ____% of calculated fluids
    50%
  117. Second hours of burn, give ___% of calculated fluids:
    25%
  118. Third 8 hours of burn give the remaining ___% of calculated fluids
    25%
  119. ___ burns are usually the ones where mannitol is given
    Electrical burns
  120. The Parkland Formula is given as a guideline for:
    Patients with electrical injury, inhalation injury, delayed resuscitation, and prior dehydration may need additional fluids
  121. Fluids are adjusted according to:
    Individual patient response... IV rate should be adjusted to maintain adequate urine output (.5ml/kg/hr (30-50/hr))
  122. When do you/ Ways to monitor Fluid Resuscitations:
    • After 1st 24 hours
    • (dextrose solutions and electrolyte replacement initiated...and albumin)

    Large amounts of fluids

    • Assess hemodynamic status
    • (avoid fluid overload)

    Hourly Urinary Output

    Management of Oliguria (diuretics are contraindicated...increase rate of fluids)

    Management of Hemochromogenuria (red, pigmented urine)

    Blood Pressure (don't base fluid regulation off BP)

    HR (tachycardia of 100-200 is common)

    Hct/ Hgb (not reliable 1st 24 hours)

    Serum Chemistries (need baseline)
  123. On people with electrical burns, you want ___ ml/hr output
    75-100
  124. Never use __ or __ to regulate fluids
    BP or HR

    (tachycardia is common 100-120)
  125. Nursing plan of care (Emergent Phase)
    • Impaired Gas Exchange
    • Ineffective airway clearance
    • Deficient fluid volume
    • Hypothermia
    • Acute Pain
    • Anxiety
  126. From beginning of Diuresis to near completion of wound closure (48-72 hours after burn injury)
    Acute/ Intermediate Phase
  127. Goals of Acute/Intermediate phase in burn pt:
    • Continued maintenance of airway
    • Continued maintenance of circulatory status
    • Fluid and Electrolyte balance
    • GI function
    • Kidney function
    • Infection prevention
    • Burn Wound Care
  128. Pulmonary complications may not appear for:
    48-96 hours

    (Acute resp. distress failure and acute resp distress syndrome)
  129. Acute Resp. Distress Failure and Acute Respiratory Distress Syndrome is characterized by:
    Upper airway edema

    Mucosal sloughing

    If ventilated (prevent ventilator associated pneumonia VAP)
  130. Cardiac Complications of Burn Pts
    • Heart Failure
    • -decreased CO
    • -oliguria
    • -jugular vein distention
    • -edema
    • -onset of S3 and S4 heart sound

    • Pulmonary Edema
    • -crackles in the lungs
    • -difficulty breathing
  131. Leading cause of morbidity and mortality in burn injury patients
    Sepsis
  132. Hypermetabolic State Causes:
    • Tachycardia
    • Tachypnea
    • Elevated Body Temperature
  133. Infection prevention for Acute/Intermediate Phase
    • Use of barrier tech
    • Environmental cleaning
    • Application of topical antimicrobial agents
    • Use of antibiotics and antifungals
    • Early excision and closure of the burn wound
    • Control of hyperglycemia (risk for infection)
    • Management of hypermetabolic state
  134. Hypermetabolism
    •Calculate Daily Caloric Need

    •Harris-Benedict equation

    •Males BEE = 66.47 + (13.75 x W) + [(5.0 x H) - (6.75 x A)]

    •Females BEE = 665.1 + (9.65 x W) + [(1.86 x H) - (4.668 x A)]

    •TEE = BEE x AF x IF x TF

    •TEE = total energy expenditure; BEE = basal energy expenditure

    •AF - activity factor: bed-ridden patient 1.2

    •active but bed-ridden patient 1.35

    •ambulatory patient 1.3

    •IF - injury factor: TBSA < 20% 1.5

    •TBSA 20-50% 1.8

    •TBSA > 50% 2.1

    •TF - thermal factor: 38 oC 1.1

    •39-- C 1.2

    •40-- C 1.3

    •41 -- C 1.4
  135. Biggest interventions about hypermetabolism
    A LOT OF CALORIES
  136. ___ are important for wound healing and energy
    Carbohydrates
  137. Limit ___ in burn pts diet
    Fats
  138. A burn patient requires ___ g of protein a day
    1.5- 2g per kg
  139. Diet for Burn pt
    High carbs/calories, High Protein
  140. Interventions of hypermetabolism
    • Calories!
    • Early excision/grafting of the burn wound
    • Insulin therapy (muscle protein synthesis)
    • Oxandrolone (anabolic steroid)
    • Propranolol (Inderal)
    • Exercise
  141. Goals of Wound management in burn pt
    Prevent infection by cleansing and debriding of necrotic tissue

    Promote wound re-epithelialization (lots of skin grafts before pt gets well...many areas of pts body to care for)
  142. Elevate all burn extremeties above the level of ___
    Heart
  143. If Transfering pt to burn center delayed more than 24 hours:
    Debride blisters >2cm

    Cleanse with Chlorhexidine Gluconate

    Apply silver sulfadiazine cream or mafenide
  144. Burns associated with extensive edema formation
    Facial burns

    • HOB 30 degrees
    • Monitor Resp Sys
  145. Interventions for burns of the eyes:
    Flucrescein used to detect corneal injury

    Instillation of mild opthalmic solutions
  146. Interventions for Burns of the Ears
    • No Pillow (compromised blood supply)
    • Blast injuries (check ears)
  147. Interventions for burns of the Hands
    • Want to maintain functionality
    • Elevate above the level of heart
    • Monitor Pulses
    • Active motion to decrease swelling
  148. Interventions for burns of the feet
    • Elevate and avoid dressing
    • Monitor Pulses
  149. Interventions for burns of genitalia and perineum
    Insert foley immediately before swelling occurs
  150. Wound Management
    • Cleansing
    • Topical Antimicromial Agents
    • Debridement
  151. Grafts for burn patients:
    must be inspected frequently

    (may cause compression)

    Dressings are typically moistened every 6 hours with Saline and polymyxin

    Donor site is covered during surgery
  152. ___ assessments of pulses with doppler
    Hourly

    (radial, ulnar, palmar...dorsalis pedis and posterior tibal)
  153. Caused by increased pressure within the fascia-enclosed muscle compartment (leads to compromised blood flow, prolonged elevation leads to death of tissue)
    Compartment Syndrome
  154. Compartment is treated by:
    Fasciotomy (done in the OR)
  155. Post Burn Pruritus:
    Oral analgesic agents???

    Frequent lubrication of skin with water or silica based lotion
  156. From the major wound closure to return to individual's optimal level of physical and psychological adjustment
    Rehabilitative Phase
  157. Nursing Plan of Care for burn pts in Rehab phase
    • Activity intolerance
    • Disturbed body image
    • Impaired physical mobility
    • Deficient knowledge
    • Less than body requirements: nutrition

    Pain management

    Nutritional Therapy

    Physical and Occupational Therapy

    Psycosocial Care

    Home Care
Author
NurseFaith
ID
288295
Card Set
Burns
Description
Burns
Updated

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