Burn Unit Flashcards
1
Q
integumentary system fxn
A
- protect from infection
- prevent loss of body fluid
- thermoregulation
- produce vit D
- excretion
- identify / appearance
- sensation reception
2
Q
burn injury patho
A
-increase infection risk
-massive fluid loss
-unable to regulate temp
-decrease vit D
-decrease ability to sweat
-change in self image
-nerve damage
3
Q
these burns have more intense pain….
A
partial thickness burns r/t exposed nerve endings
4
Q
these burns still have pain but not as much…
A
full thickness since nerve endings are destroyed, will still have tingling
5
Q
elderly are more susceptible to burns…
A
skin thins –> deeper burns, poor healing
-decreased sensation
-reduced reaction time
6
Q
thermal injury
A
skin damaged by heat
1. flame
2. scalding liquids
3. heat source
7
Q
severity of thermal burn…
A
determined by…
1. duration of contact
2. temperature of agent
3. amount of tissue exposed
4. age of pt
8
Q
children are more at risk for burns…
A
unaware of risk
unable to protect themselves
9
Q
chemical injury types
A
- contact - skin
- fume inhalation - chlorine
- ingestion / injection
10
Q
chemical injury
A
must be COMPLETELY removed / neutralized
-MSDS on units
-list every chemical on units
11
Q
alkalis chemical injury
A
deeper tissue damage , liquefy proteins on skin allowing deeper spread
ex : oven cleaners / drain cleaners
12
Q
acid chemical injury
A
coagulate the skin and proteins, LIMITING depth of damage
ex: bathroom cleaner, swimming pool cleaner
13
Q
organic chemical injury
A
fat soluble and absorbed causing damage to kidney / liver
ex: chemical disinfectants and gasoline
14
Q
chemical injury management
A
FLUSH with copious amounts of water
15
Q
consideration for dry chemical burn…
A
BRUSH IT OFF, flushing with water will activate the chemical burn process
16
Q
electrical injury
A
direct contact with electric source, WILL be an entry and exit point!!!
-has internal damage, extensive muscle damage, organs ischemic and necrotic
17
Q
cardiac electrical injury
A
EKG changes and heart damage common, related to release of potassium!!!
18
Q
musculoskeletal electrical inury
A
tetany and spasms –> fractures or compartment syndrome
19
Q
renal electrical injury
A
myoglobin release (damaged muscle tissue), circulated to kidneys
-rhabdomyosis
**cola colored urine
20
Q
important thermal questions…
A
WHEN was pt pulled from fire (heat source)
enclosed space??
pre-existing medical hx
21
Q
PRIORITY assessment for thermal injury
A
AIRWAY, could have soot in airway, hoarse voice, wheezing
22
Q
radiation injury
A
- ionizing radiation in industry
- nuclear accidents
- therapeutic radiation : chemo
**most frequent = SUNBURN
23
Q
radiation injury presents with…
A
redness, edema, blistering, pain
24
Q
burn injury severity
A
- type
- depth , extent , body part burned
- additional injury
- pt age
- pre-existing health
-major
-moderate
-minor
25
major burns
1. adult w/ >25 % total body surface area partial thickness burn
2. > 10% TBSA full thickness burn
3. burns of hands, feet, face, ears, perineum
4. inhalation
5. electrical
6. burn w/ fracture or trauma
7. high risk pt
26
moderate burns
adult w/ 15-25% TBSA partial thickness
< 10% TBSA full thickness
27
burn center pt criteria
deep partial thickness 15-25% TBSA
full thickness > 2% TBSA
burn to face, hands, feet, genitalia, joint, perineum
chemical / electrical
inhalation
co-morbidities
associated trauma
28
superficial burn (1st degree)
3 P's : pink , puffy , painful
cause : flame , SUNBURN , flash from explosion
29
partial thickness (2nd degree)
superficial partial thickness
deep partial thickness
30
superficial partial thickness
epidermis and limited portion of dermis
-blisters, bullae, serous fluid
-painful w/ sensation intact and edematous
31
superficial partial thickness cause
flame , scald , flash , contact
**heals 10-21 days
32
deep partial thickness
epidermis and most of dermis
-blisters, bullae, serous fluid
-pale ivory, waxy, moist appearance!!!
-painful w/ sensation intact and edematous
33
deep partial thickness causes
flame , scald, flash , contact
**heal 3-6 weeks
34
full thickness burns (3-4th degree)
destruction of entire epidermis and dermis , skin does NOT regrow
-down past fat, fascia, muscle, bone
35
full thickness burn pain
possibly w/ 3rd degree
MINOR in 4th degree, around edges
36
full thickness burn appearance
dried leathery eschar
white / yellow / brown with thrombosed vessels
loss of elasticity
marked edema
**needs grafting
37
full thickness treatments
amputation
fasciotomy
escharotomy
38
full thickness burn causes
flame
chemicals
high voltage
39
why is there less pain with full thickness burns....
nerve endings are damaged / destroyed
**will be pain around edges where it is only partial thickness
40
resuscitative phase
first 48 hrs until diuresis... starts pre-hospital
41
resuscitative phase goals
1. AIRWAY secure
2. circulation --> fluids!!!
3. prevent infection
4. body temp
5. emotional support
42
resuscitative phase pre-hospital
1. REMOVE source of thermal damage
2. ABCs / cervical spine
3. O2 100% , maybe intubate
4. circulation assessment
5. remove clothing / jewelry
6. trauma assessment
43
pre-hospital interventions
1. cover to prevent hypothermia --> use CLEAN DRY SHEET with > 20% TBSA
2. large bore IV and FLUID
3. pain management
4. vitals , baseline assessment
44
ED resuscitative interventions
1. AIRWAY , c-spine evaluation
2. circulation --> escharotomy or fasciotomy
3. calculate fluid requirement : pre-burn wt.
4. pain management
5. tetanus administration
45
why is it important to start an IV immediately....
once fluid shift begins it may be impossible to locate a vein
46
why should we use IV narcotics....
altered absorption via muscle and stomach
-IM / sub-q they will remain in tissue space and will be absorbed rapidly once fluid shift is resolved
47
what is the preferred pain med for burns...
MORPHINE!!!
**dilaudid if allergic to morphine
48
factors determining airway obstruction...
1. pts injured in closed space
2. pts with extensive burns or burns of face
3. intra-oral charcoal esp on teeth / gums
4. pts unconscious at time of injury
5. singed hair, nails, eyelids, eyelashes
6. coughing up carbonaceous sputum
7. voice hoarseness / brassy cough
8. accessory muscle use / stridor
9. edema, erythema, ulceration of mucosa
10. wheezing , bronchospasm
49
inhalation injuries are more likely to have....
rapid obstruction within a short time, wheezing sounds will DISAPPEAR , this demands immediate intubation
50
inhalation injury resuscitative phase
1. carbon monoxide is the leading cause of death from a fire
2. injuries above glottis
3. injuries below glottis
51
carbon monoxide poisoning
"cherry red" color from vasodilating, confusion, dizziness, headache, n/v
52
carbon monoxide poisoning tx
100% oxygen for at least 2 hrs or hyperbaric chamber
53
injuries above glottis
upper airway obstruction, common in head / neck burns and smoke inhalation
-edema will worsen with fluid resuscitation , tissues rehydrate then swell from capillary leak
54
injuries above glottis intervention...
early intubation since edema can occur within minutes to hours
55
injuries below glottis
the lungs!!!
-pts may be asymptomatic for 48 hrs
-have normal CXR and ABGs
-occurs with dry heat injury as well
56
inhalation injury 3 major points...
1. pulmonary edema = elevate HOB, humidified O2, call rapid
2. early intubation
3. CONSTANT monitoring
57
cardiac resuscitative phase
-cardiac rhythm = electrical has heart damage
-hypovolemic shock
58
fluid / electrolyte complications
1. dehydration
2. reduced blood volume
3. decreased UO
4. hyperkalemia
5. metabolic acidosis
59
elevated hematocrit....
blood is very viscous, could be sign of dehydration
60
third spacing
fluid shifts into extravascular space
-burns >20% TBSA have edema on burned area and unburned areas
61
when does maximum edema occur after burns...
24-48 hours post burn
62
kidney resuscitative phase
decreased kidney bloodflow --> acute kidney injury
-myoglobin is released from damaged muscles circulating to kidney
-will have decreased UO
63
urine output goal for burn pts...
30-50 mL / hr , pts will get foley for strict i/o every hour
64
GI resuscitative phase
ischemia r/t redistribution of blood to brain and heart
-PARALYTIC ILEUS, check bowel sounds
-H-2 blockers and PPI to reduce ulcers
-NEED BM or gas to check that GI system is working
65
metabolic resuscitative phase
increased metabolic state for up to 9-12 months post burn, increased body temp = increased metabolism
66
nonsurgical resuscitative mgmt
1. FLUIDS
2. pain management w/ narcotics
67
fluid management
based on % TBSA
-used for pts with > 20% TBSA burns
68
fluid administration times
1. half of fluid first 8 hrs from time of injury
2. second half over next 16 hours from time of injury
**all fluids need to be given within first 24 hours
**fluid overload risk, especially if they have CHF
69
fluid administration formula
4mL x kg x TBSA
70
what to hold 8-12 hours post burn on fluid management...
colloids
-blood
-albumin
-hetastarch
-plasma protein fraction
-dextran
71
albumin
pulls fluid back into the vascular space
72
electrical burn fluid mgmt
HIGHER fluid volume
-urine output needs to be 75-100 mL/hr
**myoglobin is released --> AKI
73
escharotomy
used in full thickness and circumferential burns
-loss of circulation
-loss of movement
-relieves pressure
-monitor distal pulses!!!!
74
fasciotomy
seen w/ electrical burns
-used to relieve compartment syndrome
75
acute phase
begins 48-72 hrs post burn
76
acute phase respiratory
1. CXR
2. fever
3. WBC count
77
acute phase cardiac
monitor weight
monitor i/o
-urine output is the best indiacor of intravascular fluid status
78
acute phase GI
can start tube feeds if there is bowel function
-monitor for ulcers
-will need high calories, high protein
79
acute phase skin
INFECTION IS #1 killer in this phase
-maintain joint fxn and mobility
80
acute phase wound care
1. HANDWASHING to reduce infection risk
2. isolation r/t infection risk
3. pain meds BEFORE beginning
4. change gloves when moving to different burn areas --> infection
81
acute phase debridment
mechanical
enzymatic
autolysis
surgical
82
mechanical debridement
hydrotherapy - special showers / bedside washing
**uses coarse gauze to remove dead tissue
83
enzymatic debridement
collagenase - uses enzymes
84
autolysis
moist wound healing
85
silver sulfadiazine (silvadene)
-broad spectrum / candida
-wet topical dressing
-partial and full thickness burns
-cooling effect , painless application
-may cause leukopenia!!!
-DO NOT USE W/ SULFA ALLERGY
86
bacitracin
-no gram negative / fungal coverage
-partial thickness burn wounds and grafts
-not as effective on full thickness
-BEST for use on face leave open to air
-can use ophthalmic ointment near / around eyes
87
sulfamylon cream (slurry)
-broad spectrum, effective against pseudomonas, little fungal coverage
-cream used on full thickness burns to EARS ONLY
-partial thickness burns and grafts
-wet dressing, do NOT use on large wound burns = hypothermia
-STINGING on application
88
acticoat, silverlon, mepilex
-broad spectrum, effective on MRSA and fungus
-partial thickness, donor sites
-only changed 4-7 days
-do NOT use on initial large wounds = hypothermia
-used in pts with SJS/TEN
-DO NOT use with normal saline--> will deactivate silver
-stinging on application
89
enzymatic cream (collagenase)
-no antimicrobial effects, normally mixed w/ other ointment
-full thickness, digests necrotic tissue w/o damaging good tissue
-painless application
-full thickness burns who are not surgical candidates r/t age or medical hx
90
autograft
taken from unburned area of pts own skin (DONOR SITE)
-ideal coverage for all burn pts
-permanent coverage
91
allograft
human skin from cadaver
-used as temporary covering once eschar is removed to close wound
-will start to eventually reject
92
xenograft (heterograft)
skin from other species - normally pig
-temporary coverage
-will eventually reject
93
cultured skin
pts own skin is sent to lab and grown in larger patches
-permanent coverage
-used with burns of 70% or more TBSA = do not have enough donor skin
-EXPENSIVE, very fragile, susceptible to infection
94
artificial skin
silicone membrane used to replicate dermis
-permanent coverage
-provides functional dermis
-high infection risk
95
important pt care to remember after grafts...
DO NOT SLIDE pts in bed , graft will shear off
96
infection / sepsis s/s
1. disorientation
2. decrease UO
3. metabolic acidosis
4. tachypnea
5. tachycardia
6. hyperglycemia
7. hyper / hypothermia
8. paralytic ileus
97
rehabilitative phase
begins at wound CLOSURE and ends with return to highest level of fxn
98
wound healing mobility...
as wounds heal they contract decreasing mobility
**contractures
99
splinting
during immobilization after grafting to prevent deformity
100
pressure garments
flatten hypertrophic areas and provide vascular support to healed wounds
**WEAR 23 HRS / DAY
**use 12-24 months until scar matures
101
positioning
affected extremities should be elevated at all times to prevent contractures
102
occipital pressure ulcers
reposition / turn to redistribute pressure
103
ears chondritis
caused by pressure necrosis , NO PILLOW = keeps ears free of pressure
104
neck flexion deformity
NO PILLOW
105
shoulder adduction contracture
position at 90 degree of abduction / flexion
106
wrists contracture
support in neutral position with splint / pillow
107
hand edema, claw hand, web space
elevate , resting hand splint, dynamic flexion, thumb splint
108
hip contracture
position flat, trochanter rolls at hips to prevent external rotation
109
knees contractures
elevate, avoid tight dressing, ace wraps for ambukation
110
SJS / TEN
commonly associate with...
1. medication reaction adverse
2. viral infection
3. staph toxin
111
SJS / TEN s/s
sloughing of epidermis from dermis
extremely painful lesions
SJS = < 30% TBSA
TEN = > 30% TBSA
112
SJS / TEN mgmt
1. AIRWAY is priority , sloughing of oral mucosa / bleeding
-fluid replacement
-nutrition
-wound care = need wound care nurse
-possibly burn center transfer
113
compartment syndrome s/s
1st sign is pain out of proportion to expected
-paresthesia
-pallor
-paralysis
-pulselessness!!! LATE SIGN
-pressure
114
rhabdomyolysis
damaged muscle tissues r/t myoglobin
**COLA COLORED URINE
**elevated CK but normal BUN
**75-100 mL/hr UO
115
AKI
will have elevated BUN and Creatinine
