exam 3 Flashcards
minor burns information
- treated at the scene and followed up at local ED
- Full-thickness burn < 2% TBSA
OR - partial-thickness burn < 10% TBSA
moderate burns info
- treated at scene, transported to burn center or specialized facility
- FTB 2-10%
OR
-PTB 15-25%
Major burns info
- require emergency treatment at closest facility, then transfer to burn center immediately
Major burn criteria
- FTB > 10%
- PTB > 25%
- > 60 yo
- has chronic cardiac, pulmonary, or endocrine condition
- presence of electrical burn
- presence of inhalation injury or other complicated injury
- burns to eyes, ears, face, hands, feet, or perineum
superficial thickness burn
- damage to epidermis
- pink to red, no blisters, mild edema, no eschar
- painful/tender, sensitive to heat, heals in 3 to 6 days, no scarring
superficial partial thickness burn
- damage to entire epidermis and some parts of dermis
- pink to red, blisters, mild to moderate edema, no eschar
- painful, heals within 2 to 3 weeks, no scaring but minor pigment changes
Deep partial thickness description
- damage to entire epidermis and deep into dermis
- red to white, blisters rare, moderate edema, eschar soft and dry
- painful and sensitive to touch, heals in 2 to 6 wks, scarring likely, possible grafting
full-thickness burn description
- damage to entire epi and dermis, can extend into subcutaneous, nerve damage
- red, black, brown, yellow or white; no blisters; severe edema; eschar hard and inelastic
- sensation minimal or absent, heals within weeks to months, scarring, grafting
deep full thickness burn description
- damage to all layers, extends to muscle, tendons, and bones
- black, no blisters, no edema, eschar hard and inelastic
- no pain, heals within weeks to months, scarring and grafting
s/s inhalation damage
singed nasal hair, eyebrows, eyelashes
sooty sputum
hoarseness
wheezing
edema of nasal septum
smoky smealling breath
indications of impending loss of airway
- hoarseness
brassy cough
drooling
difficulty swallowing
audible wheezing
crowing
stridor
CO inhalation s/s
h/a, weakness, confusion, erythmea, upper airway edema followed by sloughing of respiratory tract mucosa
older adults are at higher risk of what when burned?
- damage to subcutaneous tissue, muscle, connective tissue, and bone (b/c of thinner skin)
- complications from burns b/c of chronic illnesses
Resuscitation phase of burns
initial fluid shift, occurs in first 12 hrs continues for 24 to 36 hrs
- priorities include: securing airway, support circulation and organ perfusion by fluid replacement, manage pain, prevent infection, maintain body temp, provide emotional support
Labs for resuscitation phase
- glucose: elevated
- BUN: Elevated
- Hct and Hgb: elevated
- Na: decreased b/c third spacing
- K: increased due to cell destruction
- Cl: increased
- plasma lactate: elevated
- carboxyhemoglobin: >10 = smoke inhalation
- ABGs - metabolic acidosis
- protein blood albumin decreased
Fluid remobilization phase of burns
starts at 24 hr, diuretic stage begins 48 to 72 hr after injury
labs for fluid remobilization phase
- Hgb and Hct: decreased
- Na: decreased
- K: decreased
- WBC: increase, then decrease
- glucose: elevated
- ABGs: slight hypoxemia and metabolic acidosis
- protein and albumin: low
acute phase of burn
- begins 36 to 48 hr after injury
- ends when wound closes
- priorities: assess and maintain CV, resp, GI systems, wound care, pain control, psychosocial interventions
rehabilitative phase of burn
- when most of burn area has healed
- ends when client achieves highest level of functioning possible
- can last for years
nursing care to stop the burning process
- remove clothing or jewelry that may conduct heat
- apply cool water soaks to run cool water over the injury
- flush chemical burns w/ a large volume of water
- cover the burn with a clean cloth to prevent contamination and hypothermia
- perform ABCDE
- provide warmth
nursing care for minor burns
- provide analgesics
- cleanse with mild soap and tepid water; avoid friction
- use antimicrobial ointment
- apply nonadherent, hydrocolloid dressing if clothing is irritating burn
- avoid greasy lotions or butters
- determine need for tetanus shot
s/s of resuscitation phase for moderate and major burns
- tachycardia
- increased respiratory rate
- decreased GI motility
- increased blood glucose
respiratory system and moderate/major burns nursing
- assess respiratory rate and depth
- monitor chest expansion
- upper airway edema may become pronounced 8 - 12 hr after beginning fluid resusitation
- provide humidified supplemental o2
- support airway and ventilation (may need mechanical vent and paralytic meds if PaO2 is < 60 mmHG)
- monitor and maintain chest tubes
- suction q1h or as needed
- perform chest PT and have client cough, breathe deeply, and use incentive spirometer
CV system and moderate/major burns nursing
- monitor central and peripheral pulses
- capillary refill
- pulse ox
- BP
- ECG changes or presence of edema
fluid replacement and moderate/major burns nursing
- initiate IV access w/ large-bore needle; if large are aburn use of central venous catheter or intraosseous catheter
- fluid resuscitation must meet individual client’s needs
- administer HALF of total 24-hr IV fluid volume within FIRST 8 HRS from time burn occurred and remaining half over next 16 hours
- infuse 0.9% NaCl or lactated ringers
- infuse albumin or synthetic plasma expanders after first 24 hr of burn recovery
- monitor VS
- assess fluid overload
- weigh client daily
- ensure output of 30 mL/hr
- prepare to administer blood products
- monitor for manifestations of shock
- IF urine output is below request prescription to increase fluid replacement DO NOT ADMINISTER DIURETICS
comfort management and moderate/major burns nursing
- avoid routes other than IV during resuscitation phase
- use IV opioid analgesics or anesthetics
- monitor for respiratory depression when administering opioid analgesics
- use PCA
- administer meds before dressing changes
- instruct client to pat rather than scratching to relieve itching
thermoregulation and moderate/major burns nursing
- for decreased temp: use warm, inspired air, warm room, warming blankets, and warmers for infusing liquids
- low-grade fever - occurs later after first few hrs following injury can remain increased for several weeks
system and moderate/major burns nursing
- may need NG tube insertion
- monitor stool, vomitus, and gastric secretions for blood
- asses for hypomotility and for tolerance of feedings
