Functions: protective barrier against microbes and injury, maintains fluid balance Is essential for life

Burns T2 Flashcards by Rachel P

Largest organ of the body

Skin

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•Two major layers If skin

Epidermis

* Dermis

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Functions of skin

Functions: protective barrier against microbes and injury, maintains fluid balance
Is essential for life

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The severity of injury is related to the burn’s…

what?

●Depth
●Extent
•Location
•Length of exposure to the burn agent as well as victim’s age and health status at the time of injury.

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outer layer of the skin, contains sweat and oil glands and hair follicles, it can grow back, has no blood vessels: nutrients must diffuse from dermis

Epidermis

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thicker than epidermis, made up of collagen, fibrous connective tissue, and elastic fibers. Contains blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous glands, and sweat glands

Dermis

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When a burn occurs, skin can regrow as long as at least part of the dermis is present.

When can skin not repair it’s self?

When the entire dermal layer is burned the skin can not restore itself.

Subcutenous layer is below dermis then bones, tendons, muscles

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With burns The extent of problems is related to what?

age, general health, extent of injury, and the specific body area injured.

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What body areas might lead to greater injuries than others?

What general health problems might lead to worse outcomes?

Face, airway, chest, head, neck burns make it worse

Advanced age , poor skin integrity, immunocompromised

Length of exposure and age

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?? in wound healing is a key factor for all problems and a major cause of disability and death

A lack or delay

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Greater than ___% can lead to systemic response* (severe burn can lead to

– hypovolemic and cellular shock, fluid shift of plasma, electrolytes and proteins into the wound

Classified as minor, moderate, or major

Risk for infection increases with this?

Table 26-2** look up

25%

Systemic response-Burn shock

Hypovolemic/electrolyte abnormalities

Sepsis risk increases

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Body area is divided into multiples of 9%
Estimation of It does not account for depth of burn

26-10

4.5% posterior and 4.5 anterior head
4.5 posterior and 4.5 anterior arms
18% posterior 18% anterior chest and stomach(9% for just chest or just stomach)
9% for posterior and anterior legs
Genitalia - 1%

Just anterior chest=9% anterior abd 9% same for upper and lower back

TBSA

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The client has burns covering the chest, right arm and right leg anteriorly. The posterior side has half of the chest and all of the right arm and leg.

Calculate the TBSA?

40.5%

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Table 26-1

What increases severity of burn thickness ?

Skin thickness varies by ?

Varies by body part

Areas where the skin is thing (eyelids) short exposure may cause serious burn.

Thin skin in elderly also increase risk of severity even at lower temps and exposure times

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Burns are classified as:

Superficial-thickness (1st Degree)
Partial-thickness (2nd Degree)
Full-thickness (3rd Degree)
Deep full-thickness

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_____have least damage, only epidermis is involved. Caused by prolonged exposure to low heat (sunburns) or flash (short exposure to high heat). Typically no scar. Desquamation (peeling of dead skin) occurs in 2-3 days. Redness with mild edema

: entire epidermis and varying depths of dermis. Blanch when pressure applied. Blisters caused by damaged cells and vessels, bring plasma to the area. Painful, heal 10-20 days. Scarring may occur. Deep partial thickness burns may not blister, appear dry red/white center. May need skin grafting and takes 2-6 weeks to heal with scar formation

Entire epidermis and dermis burned. Not able to regrow on own. Hard eschar present. Eschar is dead skin and must be removed before healing can occur. Require skin grafts. Edema is severe.

beyond skin and damage muscle, bone, tendons. Occur with flame, electrical, or chemical. Amputation may be needed

Superficial

Partial thickness

Full thickness:

Deep- full thickness:

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Superficial to partial thickness treatments

Treatments
Cool bath of 5-15 min.
Aloe vera- superficial burn
Bacitracin/silvadine- mild partial thickness
Do not rub
May cover with light gauze change daily
Avoid further contact with source
These treatments depend on the extend (percent of body burned and type of burn)

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Involve epidermis, dermis, fascia and tissues
No pain where full thickness is involved
Will require grafting

Best thing to do for pain with this burn type?

Full thickness

Cover with light gauze to stop airflow

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Burns can effect what body systems ?

Vascular
Cardiac*
Pulmonary
GI*
Metabolic
Immunologic*

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Vascular changes in burns

Circulation is disrupted immediately

Macrophages release chemicals that cause blood vessel constriction

Thrombosis may occur causing necrosis

Fluid shifts occur as a result of blood vessels near burn dilating and leaking fluids

Capillary leaking syndrome

Third spacing or capillary leaking: continuous leak of plasma from vascular space into interstitial space. Causes fluid and electrolyte imbalance (water follows plasma), decreases blood volume, and blood pressure.

Fluid shift and cell damage causes electrolyte imbalances: hypovolemia, hyperkalemia, hyponatremia, and metabolic acidosis. Oozing and dressing changes needed frequently

After fluid shifts begin to resolve: hypokalemia can occur as potassium moves back into the cells.

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Cardiac changes in burns

Why does cardiac output decrease?

Initial fluid shifts and hypovolemia.

Improves with what?

Heart rate increases

Cardiac output decreases

Improves with fluid resuscitation

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Pulmonary changes in burns

Major causes of death?

Inhalation/Injuries result from ?

Direct injury to lungs rarely occurs
Problems cause from-
Super heated air
Toxic fumes
Smoke
^Major cause of death

*be aware of inhalation injuries:-more common to die from this first

Injuries result from:
airway edema from pulmonary capillary leaking

Chest burns that restrict lungs/circulation *
CO poisoning

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Observe for what with airway injuries?

Observe for soot around mouth
Hoarseness
Coughing/drooling
Wheezes
Intubate early-to avoid complications

Changes in respiratory patterns, hoarseness, brassy cough, drooling, difficulty swallowing, audible wheezes, stridor. Wheezing idncates there is at a minimum of partial airway obstruction

If wheezing stops, this may be a bad sign (no air is able to move past swollen pathway)

These changes indicate damage and the need to prepare for intubation

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Prevents oxygen from attaching to the heme portion of hemoglobin

PaO2 levels can remain normal

Oximeter readings can be normal

One of the leading causes of fire related deaths
S&S headache, vertigo, cherry red mucous membranes

Carboxyhemoglobin forms

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GI issues with burns

Decreased blood flow Motility decreases Secretions and gases collect: distention Curling’s ulcer* Curlings ulcer: acute gastric ulcer that occurs with the stress of sever injury. May develop within 24 hours. Becoming less common due to H2 histamine blocker or PPI use in ICUs

Burns greatly increase _____needs? Patients oxygen need and calorie need are high Increases core body temp Calorie needs can double or triple, peaks 4-12 days after burn and can remain elevated for months

Metabolic changes and needs in burns

Immunological changes

Burns disrupt the protective skin tissue integrity Injury activates inflammatory response

Mechanisms of burns (different ways burns affect the body)

Electrical burns Thermal burns Chemical burns Radiation burns

____caused by steam, hot water scalds, flames, and direct contact with heat sources

Thermal burns

________burns caused by electric shocks due to exposure to electric current or lightning

Electrical burns

_____ burns caused by exposure to strong acids, alkalis, detergents, or solvents

Chemical burns

_____burns from exposure to radioactive sources | Sunburn is a type of _____burn.

Radiation burns

This burn Entrance and Exit wound Skin injuries may be small but internal injuries greater. Contact sites may mask extent of injury. _____ converts to heat energy. Longer the content or higher the voltage, the greater the injury

Electrical energy converts to heat energy. Longer the content or higher the voltage, the greater the injury Electrical burns

Electrical wound interventions

Any metal on client will also cause a burn to body Check over entire body Remove the cause Place on cardiac monitor***

Severity depends on duration of exposure and on concentration of chemical Toxic effects to liver and kidneys Can also be inhalation Acid burns are typically self limiting and more superficial Alkaline burns can result in deep liquefaction necrosis

Chemical burns

Chemical burn interventions

Remove cause* Flush completely Decontaminate room Protect yourself

___________? Phase :1st 24-48 hours after a burn remove cause, stabilization of immediate health concerns Airway, circulation, fluid replacement, comfort, prevention of infection, maintain body temp, prevention

Resuscitation

_______days after- 48 hours after burn may last weeks to months, till wound is healed and is the process of acute burn healing

Acute phase

focus is recovery of strength and function, maximization of physical repair of tissue and psychological restoration of individual Physical therapy, tx more scar tissue may still be occurring Undetermined Amt of time

Rehabilitative phase:

Resuscitation phase interventions

``` Remove cause (unless stuck in them) MONITER Vital signs ABC’s Record vital signs, and obtain height and weight measurements. Cover with a blanket-reduces pain ``` Place a cardiac monitor on client Assess for other injuries Need a preburn weight is used to calculate fluid rates, energy requirements and drug doses. It is considered the client’s dry weight (before edema)* Need height to calculate Total Body Surface Area (TBSA)* Airway assessment is your priority* Airway- Respiratory status –Cough? Initiate oxygen therapy. Cardiac monitor Begin immediate measures to prevent hypostatic pneumonia. Measure pulse ox, blood gases, and pH frequently to determine respiratory status and general body status. Monitor serum carbon monoxide level if an inhalation injury is suspected. Administer respiratory therapy as prescribed. ***All meds via IV Humidified oxygen Arterial oxygenation less than 60mmHg require intubation

Fluid and electrolyte balance in resuscitation stage? Nursing considerations? Complications?

Fluid and electrolyte balance * Fluid replacement maintains circulating volume and prevents circulatory collapse. Use of crystalloids , isotonic or hypertonic They lose a lot of fluid- ensure hydration in this stage* *Nursing considerations *: •Goal: urinary output of 0.5 to 1 milliliters per kilogram per hour, heart rate <120 beats per minute, and systolic blood pressure >100 mm Hg •Renal function –Hourly UO for the first few days. –Specific gravity –Acidosis is a frequent complication. *Hypovolemic shock Invasive blood pressure monitoring may be needed Initially see tachycardia, decreased BP, Decreased peripheral pulses. Peripheral edema will occur with fluid resuscitation Need to have blood flow to the kidneys for them to filter

Used to calculate fluid replacement 4 ml of LR x body weight in kg x percentage of burn **The first half of the total amount calculated is given in the first 8 hours after the injury. The second half is administered over the following 16 hours

Parkland formula Fluid resuscitation is by formula Parkland formula 4mL/kg/TBSA Half of the total volume is infused first 8 hours of injury In next 16 hours remaining fluid is given and titrated with electrolytes Calculated from the time of burn and the time of arrival

Parkland formula example 180lb male 55% TBSA burn Give 4ml/kg What is the total amount to be infused? What is the infusion rate for the first 8 hours? What is the infusion rate for the next 16 hours?

18000 9000 4,500-8 hr 4,500-next 8 hrs

Leading cause of death for people with burns * Expect to administer a what due to open skin? Monitor the client’s WBC. Neutrophils will first rise and then drop. You will see a left shift. May become septic if the WBC is 2000 or less

Infection!! And then pulmonary issues Prevent infection Administer tetanus immunization.

•Pain management in burns Why might one need more meds? How to give ?

Varies due to Depth of injury, anxiety level, previous experiences with pain, cultural beliefs, and the type of invasive monitoring and wound care procedures needed affect the client’s pain level -everyone feels pain differently. Narcotic administration via a patient-controlled analgesia (PCA) device is the standard for pain relief. ** Alternative theory Never apply ointments or salves to an extensive burn, do not rub * •Salves may also introduce pathogens into wounds. –Note any changes in vital signs, such as tachycardia or a rise in temperature.-can be sign of sepsis (May not always see fever)* Give pain medication 30 minutes prior to wound change to help with pain ** May need more pain meds due to high metabolic level * Give pain meds via PCA or continuous IV infusion **

Number the following actions in the order they should be done in the emergency management of a burn of any type. ___ Establish and maintain an airway ___ Assess for other associated injuries ___ Establish an IV line with a large-gauge needle ___ Remove the patient from the burn source and stop the burning process

2,4,3,1 ___ Remove the patient from the burn source and stop the burning process ___ Establish and maintain an airway ___ Establish an IV line with a large-gauge needle ___ Assess for other associated injuries

Burn phase? Multidisciplinary approach - who is involved? Pain management is continued From approx. 48 hours until healed (May be weeks, months, years)

Acute phase Nursing care, pain management, critical care, dietician, respiratory therapy

Dressings-which phase is this done in? Gauze: impregnated with an antibiotic or drug Moist packs soaked in silver nitrate-wet dressing Synthetic dressings: DuoDerm, OpSite, Vigilon, and Biobrane Open dressings: continuously applied as wet dressings. **Tight occlusive dressing, face mask, or pressure dressing: prevents development of what?? Topicals **Who determines type of dressings used?

Acute phase Doctors orders or wound care specialist Prevents development of keloid (scar) tissue.

Is for removal of dead tissue What is this called and which phase is this done? Why is this important?

Debridement Skin can’t heal or grow if black Escar is present. Must get down to living tissue for the wound to heal.

thick, dry, and black or dark brown dead tissue Must be debrided to expose living tissue for successful grafting

Eschar

Methods of debridement

Laser scalpel Enzymatic debridement Surgical

Done to replace tissue that cannot heal by itself or to limit the amount of scarring Sometimes done on larger wounds why? Which phase is this done in?

Skin grafting Done with larger wounds because it will help heal faster and limit scaring amount Acute phase

graft using the client’s own skin

Autograft

graft using cadaver skin or skin from another person

Homograft or allograft:

graft using pigskin

Heterograft or xenograft:

biopsy is performed on unburned skin to grow new skin

Cultured epithelial autografts (CEA):

Other care management priorities with burns: Monitor gastric ____?* ______, and _______function test results. High calorie intake Record food intake up to ______calories a day, monitor daily ______, Monitor perfusion of _____ extremities ______ Status **Monitor for complications (review from book with nursing interventions related to complications)

Gastric Ph Electrolyte and renal 6000 calories , daily weights Distal extremities Respiratory status

is an acute gastroduodenal ulcer occurring within 24 hours of severe stress. Results from decreased GI blood flow and mucosal damage. Ptients are started on medications such as H2 histamine blockers, PPI, drugs that protect the GI tissues Clients with >_____TBSA likely will have NG to prevent aspiration and to decrease gastric secretions

Curling’s ulcer Greater than 25 TBSA

Don’t use or do what what with burns?

Don’t use ice Don’t use butter or other ointments Don’t break blisters- let heal on own

What does the Rehabilitative phase consist of?

Diversion activity Therapies - getting back to previous function before injury Assistance in arranging for care of the client’s family during hospitalization and the rehabilitation Financial assistance- find resources for patient Discharge planning last step in rehabilitative phase

Pulse oximiter doesn’t know the difference between oxygen and co2 so it may read 100% when oxygen is compromised

True

How to find exit wound in electrical burn

Do full assessment of entire body

Which skin graft is most commonly used?

Autograft-clients own skin Homo graph-from another person

Complications of curlings ulcer

``` Bleeding Anemia Strictures Perforation Peritonitis Gastrocolic fistula Gastric outlet obstruction due to strictures Hemorrhagic shock Increased length of ICU stay Death ``` -decreased gastric mucus production and increased hydrogen ion production in GI

Burns T2 Flashcards

(64 cards)