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Flashcards in Burns Deck (21):
0

Patho of burns

Increased capillary permeability (from vessel damage) > plasma leaking into tissues. Mostly in the first 24 hours.

Pulse increases because of a FVD. Cardiac output decreases.

Urine output decreases>trying to hold onto fluid or they are not being perfused.

Epinephrine secreted to ^BP, it vasoconstricts and shunts blood to vital organs.

ADH and aldosterone secreted>Retain Na and water with aldosterone and Retain water with ADH. Therefore, the blood volume will go up.

1

Airway injury

What is the most common airway injury? carbon monoxide poisoning
• Normally, oxygen binds with hemoglobin. Carbon monoxide travels much faster than oxygen.... Therefore, it gets to the hemoglobin first and binds....Can oxygen bind now? No
• Now the client is hypoxic.
•tx: 100% oxygen
• From this information, do you think it would be important to determine if the burn occurred in an open or closed space?
• When you see a client with burns to the neck/face/chest you had better think what? Airway
*What might the physician do prophylactically?
ET tube before the airway starts to swell.

2

Rule of 9s

Head and neck= 9%
Trunk front= 18%
Trunk back= 18%
Each arm= 9%
Each leg=18%
Genitals=1%

3

Parkland formula fluid resuscitation.

(4ml of LR) X (body weight in kg) X (% of TBSA burned) = total fluid requirement for the first 24 hours after burn
1st 8 hours = 1⁄2 of total volume (if you miss 2 hrs, must give over 6 hours)
2nd 8 hours = 1⁄4 of total volume
3rd 8 hours = 1⁄4 of total volume

4

Burns > 20-25%

. Fluid Replacement:
• One of the most important aspects of burn management is fluid management.
• know what time the burn occurred.
• Why? Fluid therapy (for the first 24 hours) is based on the time the injury occurred , not when the treatment was started.
Common rule: Calculate what is needed for the first 24 hours and give half of the volume calculated during the first 8 hours. This is the parkland Formula.
• If the client is restless it could suggest three problems: inadequate fluid replacement, pain, or hypoxia.
*Nurse’s Priority: hypoxia
• Which of the following would you choose to determine if a client’s fluid volume is adequate? Their weight or their urine output? Urine output.

5

Emergency management

Burning still continues after flames are gone. Use cool water (not ice) to stop the burning process.
Wrap in a blanket to hole in body heat amd keep out germs.
Remove jewelry because swelling will occur, also metal gets hot. Clothing? Remove non-adherent clothing and cover with a clean dry cloth.
Signs of airway injury: singed hair, soot, coughing, dark secretions, blisters in oral mucosa.

A client’s respirations are shallow. Retain CO2>respiratory acidosis

6

Albumin med management

You know that albumin holds onto fluid in the vascular space.
Vascular volume? Increases
Kidney perfusion? Increases
BP? Increases
Cardiac output? Increases

When you start giving a client albumin, you know that the vascular volume will increase.
Therefore, what will happen to the workload of the heart?
• If you stress the heart TOO MUCH:
The client could be thrown into fluid volume excess.
If this occurs, what will happen to Cardiac Output? Goes down
Lung sounds? Wet
In a client who is receiving fluids rapidly, what is a measurement you could take hourly (hint: heart) to ensure you’re not overloading the client? CVP r/atrial pressure.

7

Pain management

• Give the least amount of narcotics necessary to relieve someone’s pain. Count respirations.
• Why are IV pain meds preferred over IM with burns? Act quickly, adequate perfusion. Is not there.

8

Immunizations

1) Tetanus Toxoid: (active immunity)
*takes 2-4 weeks to develop their own immunity
2) Immune globulin: think immediate protection (passive immunity)

Give if they are uncertain of tetanus status or in more than 10 yrs

9

Circulatory complications

A client has a circumferential burn on their arm which goes all the way around.
What should you be checking? Circulation.
• If a client’s vascular check in their arm is bad what is the name of the procedure to relieve pressure?
Escharotomy- relieves the pressure and restores the circulation, cut through the eschar.
Fasciotomy- relieves the pressure and restores the circulation, but the cut is much deeper into the tissue, cut goes through the eschar and the fascia.

Check pulse, cap refill, skin color, skin temperature.

10

Renal complications.

A Foley catheter is inserted so you can measure urine output hourly.
Is it possible that when you insert the catheter that no urine will return. Yes
Why? Kidneys are either attempting to hold the fluid or they are not being perfused adequately.

What would you do if the urine is brown or red? Call the doc. It is normal because myoglobin is released from muscle and cell damage but could lead to renal failure.

What drug might be ordered to flush out the kidneys? Mannitol. Helps save kidneys, but need to increase fluids.
If there is no urine output or if it is less than 30mL/hour, you start worrying about? Renal failure.
After 48 hours, the client will begin to diurese. Why? Because fluid is going back into the vascular space. Now we have to worry about fluid volume excess.
So what will happen to urine output now? Increases.

11

Electrolyte balance

The client’s serum K+ level is 5.8
Where do we find most of our K+? inside the cell
• With a burn, what happens to cells? Rupture, releasing K+
• So, what happens to the number of K+ ions in the serum (vascular space)? Increase.
Hyperkalemia

12

GI complications

Why do you think Carbonate/Magnesium Carbonate (Mylanta®), Pantoprazole (Protonix®), or Famotidine (Pepcid®) are ordered?
To prevent a stress/kerlings ulcer.
Antacids: Aluminum Hydroxide Gel (Amphogel®), Magnesium Hydroxide (Milk of Magnesium®)
H2 Antagonist: Ranitidine (Zantac®), Famotidine (Pepcid®), Nizatidine (Axid®) Proton Pump Inhibitors: Pantoprazole (Protonix®), Esomeprazole (Nexium®)

Why do you think the physician wants the client to be NPO and have an NG tube hooked to suction?
Because they could develop a paralytic ileus
Why?
• Decreased vascular volume
• Decreased GI motility • Hyperkalemia
If a client doesn’t have bowel sounds, what will happen to abdominal girth-increase.
• Do you think the client will need more or less calories? More cuz they are in a hypermetabolic state. Need protein and vitamin C
• The NG tube will be removed when you hear bowel sounds
• When you start GI feedings, what should you measure to ensure that the supplement is moving through the GI tract? Gastric residuals. Hold feeding if residual is >50ml
• What is some lab work you could check to ensure proper nutrition and a positive nitrogen balance? Pre albumin (most sensitive), total protein, or albumin.

13

Integumentary complications
Contractures

Contractures:
Since the client has partial thickness and full-thickness burns, they could have problems with contractures?
If they have burns on their hands, what are some specific measures that may be taken?
Wrap each finger separately.
Use splints to prevent contractures. Hyperextend the neck, head is back
No pillows,

14

Classifications of burns

Superficial thickness: formally called first degree burn; damage only to epidermis
Partial thickness: formally called second degree burn; damage to entire epidermis and varying depths of the dermis.
Full-thickness: formally called third degree burn; damage to entire dermis and sometimes fat

15

Integumentary complications
Infections

With a perineal burn, the #1 complication is infection.
What is eschar? Dead tissue that needs removed.
If it’s not removed can new tissue regenerate? no
What likes to grow in eschar? Bacteria.

16

Meds for burns

a. Silver Sulfadiazine (Silvadene®)- soothing, apply directly, if it rubs off apply more, can lower the WBC, can cause a rash
b. Mafenide Acetate (Sulfamylon®)- can cause acid base problems, stings, if it rubs off apply more
c. Silver nitrate-keep these dressings wet; can cause electrolyte problems
d. Povidone-Iodine (Betadine®)-stings, stains, allergies, acid-base problems

17

Treatment.

What type of isolation will you use with the burn client? Protective isolation, they are immunosuppressed.

Sutilanis (Travase®) or Collagenase (Santyl®): enzymatic drug→ eats dead tissue
Don’t use on face. Don’t use if area is opened to a body cavity. Don’t use if pregnant. Don’t use over large nerves

Hydrotherapy is also used to debride. Give them pain medication prior to hydrotherapy
Worry about cross contamination
Why should these antibiotic drugs be alternated?
Bacteria will build resistance or tolerance.
Broad spectrum antibiotics are avoided to prevent superinfections or secondary infections.
Broad spectrum antibiotics may be used until the wound cultures have returned.
Always make sure that the cultures have been collected before you start the antibiotics.
When giving mycin drugs....we WORRY when the client’s BUN or creatinine increases or if the client complains of any hearing loss. Mycin drugs can lead to ototoxicity (irreversible hearing loss) and/or nephrotoxicity.
Check their BUN and creatinine; if they are increasing, assume they are nephrotoxic.

18

Skin grafting

Remove the burned dead tissue until healthy tissue is seen.
• Good skin is taken from a healthy donor site and placed over the burned area.
• Now the donor site is an open wound, so a transparent dressing is applied until bleeding stops.
• Then the donor site can be left open to air.
• If the client is well nourished, they can reharvest from the same donor site
every 12 to 14 days.
• If the skin graft should become blue or cool what would this mean? Poor circulation
• Sometimes the physician will order for you to roll sterile Q-tips over the graft with steady, gentle pressure from the center of the graft out to the edges. Why? Get anything out from under it. If graft is displaced, place sterile saline dressing over graft, cover site, call the doc.

19

Chemical burn

Chemical burn? First remove the client from the chemical and begin to flush.
How long do you flush? 15-20 minutes.
Brush off any powder chemical first.

20

Electrical burn

2 wounds. What are they? entrance and exit
• What is the first thing you do for an electrical injury? Continuous heart monitor for 24 hrs
• What arrhythmia is this client at high risk for?
VFib
• With electrical burns myoglobin and hemoglobin can build up and cause kidney damage.
• The client may be placed on a spine board with a c-collar. Why?
Electrical injuries occur in high places, muscle contractions can cause fractures, and the force of the electricity can actually throw the victim forcefully.
• Are amputations common? Yes. Why? Circulatory system is compromised
• Other complications of electrical wounds: cataracts, gait problems, and just about any type of neurological deficit.