Chapter #26 Burns Flashcards
Pathophysiology of burn injury?
Skin changes
anatomic changes
functional changes
temperature
Depth of burn injury
Depends on the severity and differences in skin thickness
Superficial burns
Lease damage, epidermis is only part of skin that is injured
Desquamination
Peeling of dead skin occurs 2-3 days after brun. Superficial burns
Resuscitation Phase
1st Phase of burn injury: Begins at onset of injury and lasts 24-48 hours.
Priorities during Resuscitation Phase
Secure airway, organ perfusion, support circulation, keep patient comfortable with analgesics, prevent infection, maintain body temp, emotion support.
When do you call Rapid Response for a patient in resuscitation phase?
When patient is hoarse, has brassy cough, drools, has difficulty swallowing, produces audible breath sound on exhalation. Give oxygen ASAP, then call Rapid response.
Carbon Monoxide Poison levels
Normal (1-10%) - Threshold to visual stimuli.
Mild Poison (11-20%) - Headache, SOB, decrease in vision, decrease cerebral.
Moderate (21-40%) - Headache, tinnitus, nausea, drowsy, vertigo, confusion, altered mental state.
Severe (41-60%) - Coma, Convulsions.
Fata (61-80%) - Death.
Priorities during Resuscitation Phase
Secure airway, organ perfusion, support circulation, keep patient comfortable with analgesics, prevent infection, maintain body temp, emotion support.
Nursing Intervention when manifestations of pulmonary edema are present?
Elevate head of bed to 45 degrees, apply oxygen, notify burn team or Rapid Response.
Culture Considerations for African-American Patients that are burn victims?
Sickle cell prep is performed if sickle status is unknown. Trauma of burn can trigger a sickle cell crisis in patients who have disease or carry that trait.
Carbon Monoxide Poison levels
Normal (1-10%) - Threshold to visual stimuli.
Mild Poison (11-20%) - Headache, SOB, decrease in vision, decrease cerebral.
Moderate (21-40%) - Headache, tinnitus, nausea, drowsy, vertigo, confusion, altered mental state.
Severe (41-60%) - Coma, Convulsions.
Fata (61-80%) - Death.
Interventions for signs of respiratory distress or change in respiratory patterns
Document and report to burn team and Respiratory therapist ASAP.
When intubation has not been performed in a patient whose upper airways were exposed to heat or toxic gases, what do you do?
Continually assess upper airway for recognition of edema and obstruction.
Nursing Intervention when manifestations of pulmonary edema are present?
Elevate head of bed to 45 degrees, apply oxygen, notify burn team or Rapid Response.
Culture Considerations for African-American Patients that are burn victims?
Sickle cell prep is performed if sickle status is unknown. Trauma of burn can trigger a sickle cell crisis in patients who have disease or carry that trait.
Acute Phase of burn injuries
Wound infection, 36-48 hrs after injury, grieving process
Rehabilitative Phase of burns
Scarring and contracture formation, psychological problems, loss of function and deformities
Resuscitation/Early Phase of burns
Continues for about 24-48 hrs after injury, maintain airway…. theres more to add here i think
Injuries to respiratory system
Direct airway injury, Carbon monoxide poisoning, thermal injury, smoke poisoning, pulmonary fluid overload, external factors, facial edema
Nonsurgical management: Acute Phase
Mechanical debridement- Hydrotherapy
Enzymatic debridement- Autolysis, Collagenase
Fluid Shift
Third spacing or capillary leak syndrome, occurs in 12 hr, can continue 24-36 hr after.
Profound imbalance of fluids
Kidney and Urinary Assessment for burn patients
Myoglobin released from damaged muscle circulates to kidney. Check kidney function, BUN, serum creatinine
How to give opioids to burn victims in resuscitation phase?
Give via IV route to prevent delayed rapid absorption leading to lethal blood levels.
