Flashcards in AHII Burns Deck (65):
wet-to-damp saline moistened gauze
mechanically removes necrotic debris
continuous wet gauze
wound is continually bathed with a prescribed solution; promotes dilution of exudates and soften dry eschar
topical enzyme prep
provides proteolytic action on thick and adherent eschar' this causes breakdown of the denatured protein and more rapid separation of necrotic tissue
spontaneous separation of necrotic tissue is promoted by autolysis
provides homeostasis, debridement, absorption, and protection
can be used as packing for deep wounds and for infected wounds. Requires a secondary dressing for securing. Change when dressing is saturated (q3-5 days)
provides protection, and debridement after eschar removal. May be used for dormant or nonhealing wounds that do not respond to other topical therapies. May be used for burns or before pigskin and cadaver skin grafts. Conforms to uneven wound surfaces; reduces pain. Requires a secondary dressing for securing. Topical growth factors are changed daily
continuous dry dressing provides absorption and protection. Continuous wet dressing provides protection, a means for the delivery of topical treatment and debridement. Wet to damp dressing provides atraumatic mechanical debridement. May be painful on removal. change dressing if Clean base q12-24hr; change dressing with necrotic base q4-6hr
provides absorption, protection, insulation, and debridement. Conforms to uneven wound surfaces. Requires secondary dressing for securing. When dressing is saturated, change it.
what is water heater temp setting?
no higher than 120 degrees F
provides absorption, protection, and debridement. Is waterproof and is painless on removal
partial thickness burn
will be wet
full thickness burn
will be dry
provides absorption, protection, and debridement. Conductive to use with topical agents. Conforms to uneven wound surfaces but allows only partial wound visualization. requires a secondary dressing for securing. can promote the growth of pseudomonas and other MO's
adhesive transparent film
provides protection for partial-thickness lesions, debridement, and serves as a secondary dressing. Provides good wound visualization. Is waterproof and reduces pain. Use is limited to superficial lesions. Is nonabsorbent, adheres to normal and healing tissue.
What is important to remember with a chemical injury?
tissue destruction may continue for up to 72 hours after a chemical injury
actions to take in the ED for a client with a burn injury
1. Assess airway
2. administer oxygen as prescribed
3. obtain VS
4. start IV and begin fluid replacement (prevent hypovolemic shock)
5. elevate extremities if no Fx are obvious (prevents hypovolemic shock)
6. keep client warm and NPO
rule of 9's for estimating burn percentage
Head: 9% (half anterior, half posterior)
Body: 36% (half front, half back)
Each Arm: 9% (half front, half back)
Each leg: 18% (half front, half back)
NOT RELIABLE FOR CHILDREN!!
blood supply is still intact; pink-red without blisters; skin blanches with pressure; burn is painful with tingling sensation-eased with cooling.
superficial partial thickness burn
blood supply is reduced; large blisters, edema; mottled pink to red base and broken epidermis, with a wet, shiny, and weeping surface is characteristic. Burn is painful and sensitive to cold air. Heals in 10-21 days
stridor, hoarse, raspy voice, carbonaceous sputum (face or neck injury)
Intubate early!! (orotracheal) in the next hour or two, swelling will increase and you will have to trach them if you don't intubate early.
deep partial thickness burn
wound surface is red and dry with white areas in deeper parts. Blisters are not usually present bc the dead tissue layer is thick and sticks to underlying dermis. may or may not blanch and edema is moderate. Can convert to full thickeness burn if tissue damage increases with infection, hypoxia, or ischemia. heals within 3-6 WEEKS; skin graft may be needed
wound will not heal by reepithelialization and grafting may be required. Appears as a dry, hard, leathery eschar; scarring and wound contractures are likely to develop
deep full-thickness burn
muscle, bone, and tendons are damaged. Injured area appears black and sensation is completely absent. Eschar is dry and inelastic. There is no pain bc nerve endings have been destroyed.
smoke inhalation injury
AIRWAY is PRIORITY
facial burns, erythema, swelling of oropharynx and nasopharynx, singed nasal hairs, flaring nostrils, stridor, wheezing, and dyspnea. Hoarse voice, sooty (carbanaceous) sputum and cough, tachycardia, agitation, and anxiety
carbon monoxide poisoning
carbon monoxide is a colorless, odorless and tasteless gas that has an affinity for Hg 200 times greater than that of oxygen. Ocygen molecules are displaced and carbon monoxide binds irreversibly to Hb. Tissue hypoxia occurs.
Carbon monoxide blood levels:
11-20: HA, flushing, decreased visual acuity, decreased LOC, slight breathlessness
21-40: (mod poisoning): HA, n/v, drowsiness tinnitus and vertigo, confusion and stupor, pale to reddish-purple skin, decreased blood pressure, increased and irregular HR
41-60: (severe): coma, seizures
61-80 (fatal): death
result in generalized body edema and a decrease in circulating intravascular blood volume. The fluid losses result in a decrease in organ perfusion. Hct increases as a result of plasma loss.
management of a burn injury
assess for associated trauma and inhalation injury (assess oropharynx for blisters, assess voice quality, and for singed nasal hairs and auscultate lung sounds) INTUBATE?
conserve body heat
cover burns with sterile or clean cloths
administer 100% O2
administer tetanus prophylaxis
prepare client for escharotomy or fasciotomy as prescribed
electric injury damages muscle and muscle releases
myoglobin that clog up kidneys to cause acute nephrotic injury
the most reliable and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion
urine output-implement a FC!
what happens to Basal metabolic rate with a burn injury?
BMR is usually 40-100 times higher than normal with a burn injury. This affects nutrition and analgesic metabolism. Early enteral nutrition if burn >20% TBSA.
cold thermal injury
warm rapidly and continuously for 15-20 mins; avoid slow thawing, leave OTA initially, do not debride blisters
performed during hydrotherapy; involves use of washcloths or sponges to cleanse and debride eschar and the use of scissor and forceps to lift and trim away loose eschar. May include wet-to-wet dressing changes. Painful procedure; may cause bleeding
application of topical enzyme agents directly to the wound; the agent digests collagen in necrotic tissue
excision of eschar or necrotic tissue via a surgical procedure in the operating room
very thin layers of the necrotic burn surface are excised until bleeding occurs (bleeding indicates that a healthy dermis or SC fat has been reached)
the burn wound is excised to the level of the superficial fascia; this technique is usually reserved for very deep and extensive burns.
occurs for 30 mins or less to prevent increased sodium loss through the burn wound, heat loss, pain, and stress
are immobilized for 3-7 days to allow time to adhere and attach the wound bed.
care of a graft site
elevate and immobilize graft site
keep site free from pressure.
Avoid weight bearing
when the graft takes, roll a cotton-tipped applicator over the graft to remove exudate, as exudate can lead to infection and prevent graft adherence.
instruct client to avoid fabric softners and harsh detergents.
monitor for signs of infections (foul smelling drainage, increased temp, increased WBC, hematoma formation, or fluid accumulation)
irregularly shaped, pigmented plaque or plaque with a red, white, or blue toned color.
a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale
firm, nodular lesion topped with a crust or a central area of ulceration
squamous cell carcinoma
pearly papule with a central crater and rolled waxy border
basal cell carcinoma
typically burns >20% require
4 cc LR times %burn times weight in kg=VTBA
administer 1/2 in 1st 8 hours from time of burn
1/2 over subsequent 16 hours
goal is Urine output of 30cc/hr (1cc/kg/hr for kids)
DO NOT BOLUS, NO NORMAL SALINE, CHOOSE THE CORRECT RATE AND AMOUNT: CRYSTALLOIDS ALWAYS
woods lamp exam
eye exam for flash burns to face
Patients with electrical injuries or very deep tissue damage may have myoglobin in their urine, therefore they will require double the urine output to flush the kidneys of the large myoglobin cells. The amount of fluid resuscitation required is difficult to assess because you can't go by the size of the burn. If the urine is very dark, such as in the picture, increase the rate of the intravenous fluids to maintain a urine output of 100 cc/hr.
circumferential FT burn to thorax
listen for high-pressure alarm on ventilator due to inability to expand chest-respiratory compromise
circumferential burns to extremities
monitor pulses qhour
monitor for compartment syndrome (pain, pallor, paresthesia, paralysis, pulse)
>40% TBSA burned
means whole body will swell due to fluid shifts-monitor airway!
patients with sulfa drug allergies
cant use silvadene or sulfamylon topical antimicrobials
silvadene topical antimicrobial
risk of leukopenia
sulfamylon topical antimicrobial
white fire-like icy hot when you put on. medicate pt first!! dont put over large BSA-will change kidneys excretion that results in metabolic acidosis; this will go through eschar!!
gentamycin-triple antibiotic topical antimicrobial
never over more than 20% TBSA
which staff members can be assigned to care for a client with herpes zoster?
1. Nurse who never had roseola
2. Nurse who never had mumps
3. nurse who never had chickenpox
4. Nurse who never had measles
5. Nurse who never received the varicella-zoster vaccine
1, 2, 4
what are the priorities of care during the emergent phase of burn treatment?
the primary concerns are the onset of hypovolemic shock and edema formation; this phase ends when fluid mobilization and diuresis begin
Fluid resuscitation with the Parkland (Baxter) Formula
4mL LR X kg X %TBSA = total fluid requirements for first 24 hrs
1/2 given in first 8 hours
1/4 given hours 9-16
1/4 given hours 17-24
at least two large bore IV access routes are needed
a central line for fluid resuscitation and drug administration as well as blood sampling should be considered
What about colloids for burn patients?
administration of colloid (albumin) is recommended AFTER the first 12-24 hours postburn when cap perm returns to normal or near normal (otherwise, the colloid aspect will just leak out of the vasculature and make second spacing worse)
how is colloid replacement calculated?
0.3-0.5mL colloid X kg X %TBSA
2mL X kg X %TBSA (1/2 given first 8, then 1/4, then 1/4)
fun fact about ear and neck burns
no pillows! use rolled towels
midazolam (Versed) for burn patients
provides short-acting amnestic effects
oxandrolone (Oxandrin) for burn patients
promotes weight gain and preservation of lean body mass