Burns Flashcards
Superficial:
1st Degree- Sunburn, Low-intensity flash
• Skin Involvement: Epidermis
• Symptoms: Tingling, supersensitivity, pain soothed by cooling
• Wound Appearance: Reddened; blanches with pressure; dry , minimal or no edema
• no blisters
• Complete recovery within a week; no scarring
• Peeling
• Superficial- involves the first 2-3 layers of the epidermis, sunburn or minor steam burn
• Painful because of damage to the nerve endings
• 1st thing cover it with something cool (sterile water, ABD pad)
• air hitting nerve damage is what causes the pain
Partial Thickness:
second degree
• Involves all of the epidermis and part of the dermis
• Caused by brief contact with flames, hot liquid, exposure to dilute chemicals
• Skin: Light to bright red or mottled appearance; some blisters
o Mottled – bright red/pinkish appearance
• Wounds may appear wet with weeping; extremely painful and sensitive to air:
• Loss of large amounts of plasma leaking into interstitium
o Will have swelling because starting to destroy cells and they leak into the interstitium
• Heals 7-21 days
• End Fragment Mottled- marble purple looking appearance. The cells are destroyed which is why you have plasma leaking into the interstitium. Strip naked if you spill something hot on your body
Deep-dermal Partial-
Thickness (2nd Degree)- Scalds, flash flame, hot liquids
• Skin Involvement: Epidermis, upper dermis, portion of deeper dermis
• Symptoms: Pain, Hyperesthesia; Sensitive to air
o Hyperesthesia – increased numbness/tingling, increased sensation
o Make sure to cover them up, the pain is unbearable
• Wound Appearance: mottled red base with patchy white areas; broken epidermis; modest weeping surface because severe impairment in blood supply
o Modest weeping because of the damaged blood supply
• Recuperative course: Recovery up to 6 weeks; some scarring and depigmentation; contractures; Infection may convert it to full thickness
o Contractures – webbing of the skin, if in a joint then will lose ability to use them
• Make sure if spill hot liquid to take clothes off, clothes will hold in heat
• Usually no blisters here Hyperesthesia- increased numbness and tingling. Weeping because blood supple is damaged at this point. Contractures-webbing of skin granulates and is peeled back, if in the joint then they wont be able to really use them.
Full- Thickness
(3rd Degree)
Flame; Electric Current; Chemical; Prolonged exposure to hot liquids
• Oven cleaner, child/elder abuse (people hold them under hot water)
• Skin Involvement: Epidermis, entire dermis, and sometimes subcutaneous tissue; may involve connective tissue, muscle, & bone (so all three layers of the skin)
• Symptoms: Pain free, Shock, Hematuria, hemolysis; entrance & exit wounds with electrical burn
o Pain free because have burned through the nerves and can’t feel them
o Can go through vital organs and the heart (vfib) damage the tissue
o Muscle contractions
o Can break bone
o Shock can cause spinal cord injury
o From the muscle damage, muscle will release myoglobin, and can create AKI
• Wound Appearance: Dry; pale white, leathery, or charred; Broken skin with fat exposed; edema
o Leaking out into the 3rd spacing
• Recuperative Course: Eschar sloughs; grafting necessary; scarring & loss of contour and function; contractures; loss of digits or extremity possible
o Have to cut off dead skin
o Eschar – leathery and tight, lost elasticity (if swelling eschar will not stretch will have to do eschar oddity – cuts eschar to allow swelling)
o Will see severe contractures – because once it grows back the skin will not have elasticity
o Auto graft- take skin from actual pt and preferred because less likely to reget graft
• Pig skin graft, donar grafts
• Destruction of all the layers of skin down to and sometimes including the subQ tissue, can also include muscle and bone
• Patients will not complain of pain because all of the epithelial elements are destroyed,
• These burns will not granulate new skin; therefore grafting is required
• These patients are suspetibe to infection, fluid electrlyte imbalances, altered thermoregulation and metabolic disturbances
• When assessing wounds you must take into account the patients age. Extrenely young and old are at risk for deeper burns due to thin dermal layer, the elderly may have reduced sensation or blood supply.
• However when debreding these wounds it is good to premedicate with narcotics as we can never be sure hen the patient may begin to feel pain or if there are areas that are not fully involved.
What are cardinal signs of smoke inhalation?
- Look for singed nasal hair
- Hoarseness: cherry colored lips (carbon monoxide)
- Carbon particles in sputum
- Labored Breathing, tachypnea
- Carbon monoxide is most common cause of inhalation injury, because it is a byproduct of the combustion of organic materials and therefore present in smoke.
- Any burns about the face mouth, or sooting canindicate inhalation injury and intubation must occur soon
- The most common pulmonary burn complication is carbon monoxide poisoning— cherry colored lips
rule of 9s
o Total head 9% (4 ½ front and 4 ½ back) o Peritoneum - 1% o Torso – anterior 18% o Torso - posterior 18% o Left leg anteriorly 9% o Left leg posteriorly 9% o Right leg anteriorly 9% o Right leg posteriorly 9% o Right arm 4 ½ % posteriorly (entire right arm 9%) o Right arm 4 ½ % anteriorly o Left arm 4 ½ % posteriorly (total left arm 9%) o Left arm 4 ½ % anteriorly
Pathophysiology: Cardiovascular
• Hypovolemia: leaky capillaries-third spacing
o Cells are damages so goes into interstial
• Hypotension – no fluid volume circulating and are in shock
• Decreased Cardiac Output-myocardial suppression due to release of endotoxins
• Vasoconstriction- SNS activation causes catecholamine release and increased peripheral resistance
o 1st for short amount of time is vasocontriction then changes very quickly to vasodialation
o burn shock cardiovascular – hypovolemia (due to 3rd spacing and fluids, vasoconstriction (due to catecholamine release) then quickly moves to vasodilation (due to release of histamines)
• Fluid shifts
• Burn shock occurs in Patients with burns injuries on more than 20% TBSA.
• hypovoleic shock, the burning agents causes the capillaries to and small vessels to dialate resulting in increased capillary permeability. Plasma seeps into the surrounding tissue causing blisters and edema
• The fuid loss with extensive burns leads to a deficit in the intravascular fluid vol. Edema occurs at the burn sitr and in the unburned tissue
• The cardiac output is decreased due to the relaese of endotoxins
• So burn shock includes: hypovlemia due to third spacing , vasodilation due to endotoxin release and vaso dilation due to massive histamine release
• Vasodilation occurs because the of the release of histamines and endotoxins
• So to sum it up _ Burn shock = hypovolemia due to third spacing, vasodilation due to endotoxins and histamine release
• The heart rate will increase and urine out put may begin to decrease- this is due to blood loss and third spacing of the fluids.
Pulmonary Changes
- Upper Airway: Swelling, occlusion, due to insult of direct heat or edema; seen in area of pharynx & larynx
- Lower Airway: due to inhalation of noxious gases: carbon monoxide, sulfur oxides, nitorgen oxides, cyanide, ammonia, chlorine, halogens
- Cause loss of ciliary action, increased secretions, reduced surfactant production, ARDS
- Any patient that has obvious burns or sooting about the face and neck wil be intubated- this is indicative of potential damage to the airway or inhalation of noxious gases .
- Inhalation injuries danage the cillae and inhibit there function, the in crease in secrestions and reduction in surfactant can lead to ARDS the patient may require an oscillating vent or ECMO (extracporeal menbrane oxygenation)
- So the nurse would suspect the patient who is becoming more agigtated, refractory hypoxia despite 02 and requiring increased PEEP while on the vent to be suffering from ARDS– which in essence is decreased pulmonary compliance
Fluid Changes
• Edema: excessive fluid in the tissue spaces-Maximum at 24 hours. Begins to resolve 1-2 days and usually resolves by 7-10 days
• Burned tissue may be unyielding to edema underneath its surface; acts like a tourniquet particularly if burn is circumferential
o Eschar acts like a tourniquet
o Will impair respiratory because can’t expand chest – will have to escharotomy – open it up
• Edema exerts pressure on nerves and vessels, causing obstruction of blood flow similar to compartment syndrome
o Remove dead tissue and pressure with surgery
• May require ESCHAROTOMY: surgical incision into eschar to remove dead tissue and relieve pressure
• Burned tissue can constrict the tissue almost like a tourniquet when edema is present , edema can compress nerves and vessels and cause obstruction of blood flow. This can be almost like a compartment syndrome
• Sometimes the pressure must be relieved and it can be done by eschar-auto-me
Electrolyte Changes
• Na+ levels may vary; Hyponatremia is usually seen d/t fluid resuscitation
o Diluted
• Hyperkalemia (K+) occurs secondary to massive cell destruction
o Cells are damaged and potassium goes out into interstitial space
• Hypokalemia may occur later with fluid shifts – when it goes back into cell
•
• Hyponatremia may occur due to the large amount of fluid used for resuscitation- it dilutes the sodium
• Potassium levels increase due to the huge amounts of cell lysis
• Then this can reverse as fluid shifts begin to occur
Gastrointestinal Alterations
- Paralytic Ileus due to decreased blood flow
- Curling’s Ulcer: gastric bleeding secondary to stress
- Loss of GI mucosal integrity leading to translocation of bacteria from gut into bloodstream- leads to sepsis
- Treat with early enteral feeding to give calories, bc pt burning more calories due to hypermetabolic state
- Alcohol ingestion: common in burned population. Also impairs intestinal integrity and the immune response
- The abdomen and bowel sounds should be assessed every 2 hours during the initial phase of treatment and then every 4. when the papralytic ileus is suspected then a NG tube will be dropped and po intake stopped. This condition can be related to hypokalemia or decreased tissue perfusion
- The burn pt must be monitored closely for gastric bleeding therefore requiring stools and gatric content testing
Curling’s Ulcer:
gastric bleeding secondary to stress
Renal Alterations
• Decreased blood/fluid volume leading to acute renal failure
o Bc not perfusing
• If muscle damage (from electrical burns), release of myoglobin leading to rhabdomyolysis
• Will see burgundy-colored urine due to hemochromogen and myoglobin
• Treat with adequate fluid volume to flush kidneys
• * myoglobin: a ferrous globin complex responsible for the red color of muscle and its ability to store oxygen; Normal levels are
Immunologic Alterations
- Sepsis is leading cause of death in burn injuries
- Acutely problem is hypovolemia, but after that the problem is risk of sepsis
- Loss of skin integrity, release of abnormal inflammatory factors, impaired neutrophil function, loss of T cell lymphocytes and macrophages, all result in inability to fight infection
- The loss of the protective mechanism and the patients own bacterial flora can lead to sepsis
- Cross contamonation is also a cause of sepsis,
- Handwashing is important, the nurse must monitor the wounds for increased exudate , odor and color
- Prophylactic antibiotics are discouraged as the goal is to treat specific pathogens
Thermoregulatory Alterations
- Patients lose ability to regulate body temperature
- Early hours: low body temperatures
- Then hypermetabolic rate resets core temperature leading to high temperature
- 99.6-101 is where we want temperature to be
- The skin and underlying muscle and fat help to regulate temperature.once that is damaged especially in large areas the ability to regulate temp is lessened or completely gone. The core temp should be maintained between 99.6 and 101… how do we do this? When we are doing hydrotherapy, dressing changes etc.. We want to closlely monitor the core temp and turn up the heat or use heat lamps as needed
Carbon monoxide (CO) poisoning
o Normal HbCO is less than 2%
o 40% to 60% = unresponsive
o 15% to 40% = varying levels of central nervous system dysfunction
o Clinical signs and symptoms related to central nervous system and heart
• Agitated, restless,
o The affinity of hemoglobin for carbon monoxide is 250 times greater than that for oxygen overtakes the heme
o Treatment: early intubation, mechanical ventilation with 100% oxygen
For the patient with an electrical burn, what must the nurse watch for?
• Electrical and lightning: low-voltage (alternating current) or high-voltage (alternating or direct) :An electrical current immediately contracts muscles as it travels through body: cardiac dysrhythmias and spinal injuries often result. These patients are also prone to acute renal failure d/t release of myoglobin. Rhabdomyolysis
o Act like a defibilator
o Can have spinal cord injury as well
Why are burned patients at risk for a paralytic ileus?
Paralytic ileus can be related to hypokalemia (sympathetic response to trauma) or decreased tissue perfusion related to hypovolemia
