burns Flashcards Preview

NCLEX > burns > Flashcards

Flashcards in burns Deck (31)
Loading flashcards...

burns patho

increased capillary permeability causes plasma to seep out into the tissue (fluid leaks out of the vessels)

worry about shock within the first 24 hours

pulse increases r/t FVD

CO decreases r/t less volume to pump out

urine output decreases r/t kidneys not being perfused

epinephrine secreted and vasoconstrict to shunt blood to vital organs

ADH and aldosterone secreted to increase blood volume (ADH retains H2O, aldosterone retains Na and H2O)


classification of burns

burn location
risk factors



rule of 9s
head and neck 9
trunk front 18 back 18
genital 1
arm 9 (each)
leg 18 (each)



partial: 1st and 2nd degree
full: 3rd and 4th degree


burn location

face, neck, or chest: breathing issues
hands, feet, joints, or eyes: everyday issues


risk factors

heart, lung, or kidney disease
pre-existing diabetes or peripheral vascular disease (dont heal well)
young and old (thin skin and less subQ fat so burn can go deeper and cause more complications)
BSA is less in young `


treatment for burns

stop burning process (wrap in blanket, cool water no more than 10 minutes, remove jewelry, remove non-adherent clothing and cover the burns)

focus on airway

may intubate prophetically


inhalation injury

client is hypoxic
treat with 100% O2


hydrogen cyanide

treat with 100% O2
antidote at hospital
if they are in a closed space: at risk for more complications


indicators of inhalation injury

singed nose hair
singed facial hair
soot on face
coughing up secretions with dark specks
difficulty swallowing
blisteres on oral mucosa
substernal/intercostal retractions and stridor = BAD


fluid replacement for burns

2 large bore IVs
crystalloids (LR) and colloids (albumin)
*** note time of burn r/t fluid replacement in first 24 hours depends on the time the injury occurred


fluid replacement calculation

1st 8 hours: 1/2 of total volume
2nd 8 horus: 1/4 of total volume
3rd 8 hours: 1//4 of total volume

(2-4mL of LR) x (body weight in kg) x (%of TBSA burned) = fluid required in first 24 hours


nursing priority with burns



how can you tell if fluid replacement is working for those with bursn

urine output

minimum of 0.5 to 1ml/kg/hr (30-50ml/hr for adults)
electrical injuries: 75-100ml/hr
1ml/kg/hr for children


meds for burn pts

albumin (colloid)

within the first 24 hours
holds fluid in vascular space
vascular volume increased
kidney perfusion increased
blood pressure increased
cardiac output increased
**** putting more fluid in vascular space
workload of heart will increase
*** vascular volume will increase when giving albumin


albumin alert

stress the heart too much can go into FVE
cardiac output will decrease
to ensure that an infusion is not overloading the client take the CVP hourly


pain management for burn pts

assess respirations when giving narcotics
IV meds
drug of choice: opioids


immunizations for burns

tetanus (active immunity) takes 2-4 weeks to develop their own immunity

immune globulin (passive immunity) provides immediate protection


systemic antibiotic therapy

broad spectrum are avoided but will only be used until cultures have returned
collect cultures before starting antibiotics
*****when giving mycin drugs WORRY when the clients BUN or Cr increase or if they report hearing loss. mycin drugs can lead to ototoxicity (irreversible hearing loss) or nephrotoxicity


topical medications for burns

silver impregnanted dressings provide broad antimicrobial effects

can be left in place for 3-14 days

mafenide acetate: can cause acid base issues and stings
silver nitrate: keep wet, electrolyte issues
antimicrobial ointments

need to be alternated r/t drug tolerance

apply a thin layer using sterile gloves

asepsis is critical

can use light gauze to cover



used to remove necrotic dead tissue
Sutilains or Collagenase (enzymatic drugs that eat dead tissues)
dont use on face
dont use if pregnant
dont use over large nerves
dont use if area is opened to a body cavity

hydrotherapy: need to monitor pain management



autograft: own skin (dressing until bleeding stops and then left open to room air)

can reharvest from the same donor every 12-14 days if healthy

poor circulation if blue or cool

tuberculin syringe and aspirate blood or exudate from under the graft or roll qtips over the graft if air, blood, or exudate is accumulating under the graft


nutrition for those with burns

more cals
protein and vitamin C are needed to promote healing
check pre-albumin to ensure proper nutrition and positive nitrogen balance


circulation complications

check circulation if circumferential burns
elevate extremity
decreased vascular check--> escharotomy and fasciotomy to relieve pressure and restore circulation
****the fasciotomy cut is much deeper into the tissue and through the fascia of the muscle


circulatory check

skin color
skin temp


renal system for burn pt

monitor catheter hourly
kidneys retain H2O so may not have urine when inserted right away
Mannitol is used to flush kidneys
can see brown or red urine
kidney failure if output is less than 30ml/hr
diurese after 48 hours r/t fluid going into vascular space so worry about FVE


electrolyte imbalance for burn pt

most of K is inside the cell
cells rupture (lysis) during burns
serum K increases (vascular space)


GI system r/t burns

magnesium carbonate, pantoprazole, and famotidine to prevent stress ulcer (Curling's ulcer)
*** watch for occult blood in stool and coffee ground emesis

NPO and hooked up to NG suction to prevent paralytic ileus

remove NG tube when you hear bowel sounds


integumentary system r/t burns

contractures: wrap each finger separately and use splints to prevent, hyper-extend the neck (head is back), no pillows

infection: perineal=infection, eschar (dead tissue) needs to be removed and if not then it cannot regenerate, bacteria likes to grow in eschar tissue


chemical burns

remove and begin flushing the skin/surface
flush with water 15-30min (cool or sterile saline)
brush powder chemicals first and then flush