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Older Adults Part 3 > 9.2 Nursing Process for Burns > Flashcards

9.2 Nursing Process for Burns Flashcards

1
Q

Stages

A

Emergent/Resuscitative Phase
- Onset of injury until completion of fluid resuscitation

Acute/Intermediate Phase
- Beginning of diuresis until wound closure

Rehabilitation Phase
- From wound closure until return to optimal physical/psychological adjustment

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2
Q

Burn Priorities

A
  • ABC’s
  • 100% humidified oxygen for mild pulmonary injuries (encouraged to cough)
  • For severe cases bronchial suctioning to remove secretions and bronchodilators and mucolytics.
  • AIRWAY IS INCREDIBLY IMPORTANT BECAUSE AIRWAYS CAN CLOSE QUICK FROM EDEMA AND TOXIC EFFETS OF SMOKE
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3
Q

Emergent/Resuscitative Phase

A

EMS Team
- Eliminates burn source
- Supports vital functions
- Transports

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4
Q

Acute Stage

A

Emergency Team (Emergency Room)
- Fluid resuscitation
- Ventilator management

Burn Team (Burn/ICU Unit)
- Fluid management
- Ventilation
- Surgery
- Hydrotherapy
- Nutrition
- Physical Therapy
- Wound care
- Medication
- Psychosocial support

Healthcare Team (Med-Surg)
- Nutrition
- Wound care
- Physical therapy
- Medication
- Psychosocial support

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5
Q

Rehabilitation Phase

A

Social Services
- ADL’s
- Vocational training
- Psychosocial Support
- Physical therapy
- Community resources
- Follow-Up

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6
Q

On-The-Scene Care

A
  • Prevent injury
  • Extinguish fire, irrigate chemical burns, cool burn down
  • ABCs
  • Start oxygen and IV
  • Remove restrictive objects and cover the wound
  • Assess all body systems
  • Treat patient with falls/electrical injuries for potential cervical spine injury
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7
Q

ER Care

A
  • Fluid resuscitation and foley catheter
  • NG tube for 20-25% TBSA burns
  • Patient is stabilized (ABGs, VS, Carboxyhemoglobin)
  • ECG for patients with electrical burns
  • ONLY IV MEDICATIONS SHOULD BE ADMINISTERED (PAIN)
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8
Q

Math

A

Parkland
- 4mL x kg x TBSA%
- 50% of total in first 8 hours, 25% for each 8 hours after
- SECOND 24 HOURS USE CRYSTALLOID WITH 5% DEXTROSE TITRATED TO URINARY OUTPUT

ABLS
- 2-4 mL x kg x TBSA%

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9
Q

Nursing Management

A
  • ABCs
  • VS
  • Hemodynamic status
  • Monitor fluid volume deficit
  • Assess extent of burn
  • TETANUS PROPHYLAXIS
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10
Q

Pulmonary Support

A
  • Inhalation injury is a frequent cause of death in burn patients (due to smoke inhalation and cutaneous burns)
  • Inhalation injury predisposes patients to pneumonia (which increases mortality rate to 60%) - Children and elderly are especially at risk.

Goals
- Improve oxygenation
- Decrease interstitial edema and airway occlusion
- Humidified oxygen in Fowler Position
- Severe upper airway obstructions may require ET tube
- High fowler position, coughing, deep breathing, chest physiotherapy, reposition, frequent tracheal suction, incentive spirometry and bronchoscopic removal of debris.

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11
Q

Racemic Epinephrine

A
  • Aerosolized topical vasoconstrictor, bronchodilator, and secretion bond breaker

Vasoconstrict - reduces sub/mucosal edema

  • Also used to treat post-extubation stridor
  • Given every 2-4 hours as long as HR does not excessively increase
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12
Q

Medications Given for Burns

A
  • Nebulized racemic epinephrine for airway edema and obstruction. (water added as a diluent helps break bonds of secretions)
  • Secondary bronchodilator to reduce muscle spasms of bronchioles
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13
Q

Carbon Monoxide Poisoning

A
  • Carbon monoxide combines with hemoglobin to displace oxygen and forms carboxyhemoglobin.
  • Carbon monoxide has 200x greater affinity to hemoglobin than oxygen (if too much it will cause hypoxia)

Symptoms
- Anxiety
- N/V
- Weakness
- Headache
- RED SKIN

Treatment
- 100% humidified oxygen
- Intubation if needed

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14
Q

Carboxyhemoglobin

A

COHb

  • Ranges
    Nonsmokers - Up to 3%
    Smokers - 10-15%
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15
Q

Fluid and Electrotype Shifts

A

Manifestations

  • Dehydration
  • Reduced blood volume
  • Decreased urine Output
  • Metabolic Acidosis
  • Hyperkalemia (from cells releasing potassium)
  • Sodium traps in edema fluid and shifts into cells as potassium is released (hyponatremia)
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16
Q

Fluid and Electrotype Shifts

A
  • Edema forms in 4 hours from superficial burns
  • Edema takes up to 18 hours to form for deeper burns
  • Caused by increased perfusion to injured area and increased capillary permeability in that area (reflects the amount of microvascular and lymphatic damage to tissue)

Burns greater than 30%
- Inflammatory mediators stimulate local/systemic reactions causing extensive shift of fluids (electrolytes/proteins) to surrounding interstitiam.

TREATMENT FOR EDEMA
- Elevation of extremity

17
Q

Reabsorption of Edema

A
  • Reabsorption begins at 4 hours post-injury and completes 4 days after
  • Fluid resuscitation is important for tissue perfusion but can increase edema causing ischemia and necrosis (in burned and non-burned tissue)
18
Q

Immediately After Burn INjury

A
  • Hyperkalemia from massive cell destruction
  • Hypokalemia later with fluid shifts
  • Hyponatremia may occur due to plasma loss or in the first week due to water shifts into interstitial areas.
  • Anemia can also occur from destroyed RBC’s however hematocrit may still be elevated due to plasma loss
  • Thrombocytopenia and increased prothrombin times can also occur
19
Q

Complications of Burns

A
  • Acute respiratory failure
  • Distributive shock
  • AKI
  • Compartment syndrome
  • Paralytic Ileus
  • Curling Ulcer (reduced plasma volume leads to ischemia and cell necrosis of gastric mucosa)
20
Q

Escharotomy

A
  • Also used to treat edema (instead of elevation of extremity)
  • It is removal of eschar (devitalized tissue)
  • Surgical incision through eschar
21
Q

Fasciotomy

A
  • Surgical incision through fascia to decompress edema and restore tissue perfusion
22
Q

Burn Treatment

A
  • Circumferential burns to an arm or leg can mimic compartment syndrome (due to edema surrounding the entire extremity)
  • Remove rings, watches, jeweler
  • Elevation and range of motion for injured extremity.
  • Escharotomy at bed side
  • Narcotics/Benzodiazepines for comfort

HOURLY
- Assess skin color, capillary refill, peripheral pulses
- Assess HR, BP, and UO to monitor fluid resuscitation

ADULT URINARY OUTPUT
- At least 30 mL/hr
- 0.5 mL/kh/hr

23
Q

Second Phase: Acute

A
  • 48-72 hours after injury
  • Focus is infection prevention, wound care, pain management, modulation of hypermetabolic state, early mobility
24
Q

Infection

A
  • Most common cause of death in burn patients after 7 days
  • Immune system is compromised from burn
  • CATHETER MUST BE HANDLED WITH STERILE TECHNIQUE
  • STERILE GLOVES FOR DRESSING REMOVAL AND WOUND EXPOSURE
  • MONITOR SEPTIC SHOCK
25
Q

Fluid/Electrolyte Shift

A
  • Fluid re-enters vascular space
  • Hemodilution
  • Increased urinary output
  • Hyponatremia (due to loss of sodium from diuresis and dilution of vascular space from fluid re-entering vascular space)
  • Potential hypokalemia when potassium goes back into cells.
  • Metabolic acidosis
26
Q

Third Stage: Rehabilitation

A

Focus
- Wound healing
- Psychosocial support
- Self-Image
- Lifestyle
- Restoring maximal function

Interventions
- High protein diet
- Physical therapy
- Preventing scars/contractures
- Psychologic rehabilitation

27
Q

Cleansing of burn

A
  • Hydrotherapy
  • Topical agents
  • Clean with water, chlorhexidine or NS with providone iodine (Betadine) with each dressing change
  • Culture eschar and granulation 3 times a week to identify contamination

Silver Sulfadiazine
- Topical drug of choice on admission
- May cause transient leukopenia (requires CBC monitoring)
- Discontinue if WBC drops below 3000 and restart once WBC is normal again

Mafenide Acetate Cream
- Drug of choice for increased colony count (broad-spectrum bacteriostatic)
- Discomfort with this cream is common

28
Q

Debridement of Wound

A

Mechanical
- Wet-dry or Wet-Wet dressing changes

Enzymatic Debridement
- Apply proteolytic substances to burn wound to shorten time of eschar separation

Surgical Debridement
- Allows for minimal loss of viable tissue

29
Q

Dressing Changes and Grafts

A
  • Grafts locations are picked to areas of similar color, texture, and thickness

Sheet Graft
- Skin applied to surgical excised area

Mesh Graft
- Applied to burn site

  • Dressing is used to immobilize grafted area

Fish skin (tilapia) and pig skin are usually used for grafts.
- Tilapia is a great cheap way that can speed healing process

30
Q

Physiologic Support

A
  • Weekly family meetings
  • Work with psychiatric liaison nurse
  • Hallucinations, confusion, and combativeness are common
31
Q

Nutritional Support

A
  • Greater nutritional need due to stress, hypermetabolism, and wound healing
  • Goal is to promote nitrogen balance
  • Enteral route is preferred

Jejunal feedings
- lowers risk of aspiration in patients with poor appetite, weakness, and other problems.

32
Q

Home Instructions

A
  • Mental health
  • Skin and wound care
  • Exercise/Activity
  • Nutrition
  • Pain management
  • Thermoregulation and clothing
  • Sexual issues
33
Q

Toxic Epidermal Necrolysis Syndrome

A
  • TENS
  • Superficial exfoliated dermatitis (can be caused by adverse reaction to medication, staph, or viral infection
34
Q

Necrotizing Fascilitis

A
  • Rapid and progressive inflammatory infection of soft tissue
35
Q

Cold Injuries

A
  • Localized frostbite or systemic lowering of body core temperature with hypothermia

Older Adults Part 3 (54 decks)

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