Week 11: Burns & Respiratory Distress

Question 1

Burns

Answer 1

Occur when injury to the tissues of the body is caused by:
-Heat
-Chemicals
-Electric current
-Radiation

Question 2

Types of Burn Injury (Thermal Burns)

Answer 2

-caused by flame, flash, or contact with hot objects
-the most common type of burn injury

Question 3

Types of Burn Injury (Chemical Burns)

Answer 3

-results from tissue injury and destruction from acids, alkalis, and organic compounds

Question 4

Types of Burn Injury (Smoke Inhalation Injury)

Answer 4

-results from inhalation of hot air or noxious chemicals (i.e CO poisoning)
-cause damage to the tissues respiratory tract
-responsible for up to 77% of deaths, largely related to carbon monoxide poisoning

Question 5

Types of Burn Injury (Electrical Burns)

Answer 5

-caused by intense heat generated from an electric current
-May result in direct damage to nerves and vessels, causing tissue anoxia and death
-severity depends on the amount of voltage, current pathways, surface area in contact with the current, and length of time that the current flow was sustained
-Can be difficult to determine since most of the damage is below the skin

Question 6

Classification of Burn Injury

Answer 6

SEVERITY is determined by:
-Depth of burn
-Extent of burn
-Location of burn
-Client risk factors

GOALS of care:
-wound healing
-prevention of infection
-pain management
-return to preinjury function

Question 7

Classification: Depth

Answer 7

Burns are defined by degrees
1st DEGREE- superficial partial thickness burn
-involves the epidermis (sunburn)
2nd DEGREE- deep partial-thickness burn
-Involves the dermis
3rd&4th DEGREE- full thickness burn
-involves fat, muscle, bone
-significant damage to the dermis-remaining skin cells are insufficient to regenerate new skin

Question 8

Classification: Extent

Answer 8

Lund–Browder Chart:
-Considered more accurate
-Considers the client’s age, in proportion to relative body-area size, is taken into account

The Rule of Nines:
-Easier to remember
-Considered adequate for initial assessment of an adult burn client
-Commonly used in emergency

*extent of a burn is often revised after edema has subsided

Question 9

Classification: Location

Answer 9

Location of burn related to the severity of the injury
-Face, neck, chest → respiratory obstruction
-Hands, feet, joints, eyes → self-care
-Ears, nose, buttocks, perineum → infection

Circumferential burns of the extremities can cause circulatory compromise

Potential for compartment syndrome from direct heat damage to the muscles and subsequent edema and/or pre-burn vascular problems

Question 10

Patient Risk Factors

Answer 10

-Older adults heal more slowly than younger adults
-Pre-existing cardiovascular, respiratory, & renal diseases contribute to poorer prognosis
-Diabetes or peripheral vascular disease contributes to poor healing
-Concurrent fractures, head injuries, or other trauma also lead to poor prognosis
-Physical debilitation renders client less able to recover:
a.)alcoholism/drug abuse
b.)malnutrition

Question 11

Phases of Burn Management (Pre-Hospital Care)

Answer 11

-At the injury scene, priority is to remove the person from the source of the burn and stopping the burning process

Question 12

Phases of Burn Management (Emergent)

Answer 12

RESUSCITATIVE
-The period of time required to resolve the immediate, life- threatening problems resulting from the burn injury
-Lasts up to 72 h

Question 13

Phases of Burn Management (Acute)

Answer 13

WOUND HEALING
-Begins with mobilization of extracellular fluid & subsequent diuresis, and concludes when the burned area is completely covered by skin grafts or when the wounds are healed
-This may take weeks or many months
-Longest stage

Question 14

Phases of Burn Management (Rehabilitative)

Answer 14

RESTORATIVE
-Begins when the patient’s burn wounds have healed and the patient is able to resume a level of self-care activity

Question 15

Emergent Phase (Resuscitative)

Answer 15

Greatest threat is hypovolemic shock & subsequent edema
-caused by a massive shift of fluids out of the blood vessels due to ↑ capillary permeability
Toward the end of the phase:
-capillary membrane permeability is restored
-fluid loss & edema formation cease
-interstitial fluid gradually returns to the vascular space

Question 16

Capillary Permeability- Hypovolemia

Answer 16

-Inflammation
-↑ capillary permeability
-Massive shift of H2O, Na+, albumin
-Interstitial space (second spacing)
-↓ osmotic pressure
-↑ fluid shifting (third spacing)
-Intravascular volume depletion
-Hypovolemia

Question 17

Emergent Phase- Clinical Manifestations

Answer 17

Pain
-Areas of full-thickness & deep partial-thickness burns are initially anaesthetic because the nerve endings are destroyed
-Superficial to moderate partial-thickness burns are extremely painful

Most Patients are Alert & Often Frightened
-benefit from calm reassurance & simple explanations by health care providers
-If inhalation injury has occurred-the upper airway is vulnerable to edema formation and airway obstruction

Question 18

Emergent Phase Inflammation & Healing

Answer 18

-Neutrophils and monocytes accumulate at the site of injury
-Fibroblasts & collagen fibrils begin wound repair within the first 6–12h

Immunological Changes:
-widespread impairment of the immune system
-Skin barrier is destroyed
-Bone marrow is depressed
-Circulating levels of immune globulins are decreased
-WBC’s defects

Question 19

Emergent Phase (Cardiovascular System)

Answer 19

-Dysrhythmias & hypovolemic shock
-Impaired circulation to extremities
-Tissue ischemia
-Necrosis: escharotomy

Question 20

Emergent Phase: Respiratory Phase

Answer 20

-URT injury: inhalation of hot air, steam, smoke
-Edema formation: mechanical airway obstruction & asphyxia
-LRT injury: inhalation of toxic chemicals or smoke
-Pulmonary edema

Lower respiratory tract injury is concerned with impaired gas exchange

Question 21

Emergent Phase (Urinary System)

Answer 21

-Acute tubular necrosis (ATN)
-Hypovolemia: decreased kidney blood flow: renal ischemia: AKI
-Full-thickness & electrical burns: myoglobin & hemoglobin are released into the bloodstream: occlude the renal tubules
-Decreased blood flow to kidneys causes renal ischemia

Question 22

Emergent Phase: Collab & Nursing Care
(airway management)

Answer 22

PRIORITY:
airway management, fluid therapy, wound care

Frequently requires endotracheal (ET) intubation:
-extubation may be indicated when the edema resolves, usually 3 to 6 days after burn injury

Respiratory Distress
-r/t circumferential burns to neck & truck (escharotomy)

Bronchoscopy
-To assess lower airway

CO poisoning
-100% O2

Question 23

Emergent Phase: Collab & Nursing Care
(Fluid Therapy)

Answer 23

-Critical for fluid resuscitation & meds
-Establish IV access to accommodate large volumes of fluid
-Type of fluid determined by size/depth of burn, pt’s age, & pre-existing conditions
a.) lactated ringers, colloids, combo (isotonic soltn)
Adequacy of fluid replacement
-Urine output – 0.5-1 ml/kg/h
-Cardiac factors
-Mean arterial pressure > 65 mmHg
-Systolic BP >90 mmHg
-HR < 120 bpm

Question 23

Emergent Phase: Collab & Nursing Care
(Wound Care)

Answer 23

-Full-thickness burn wounds are dry and waxy white to dark brown or black
-have minor, localized sensation because nerve endings have largely been destroyed
-Partial-thickness burn wounds appear pink to cherry red and are wet and shiny with serous exudate
-Cleansing & gentle debridement to prevent infection
-Necrotic skin removed
-Coverage is the primary goal
-Moist wound healing and use dressings to cover
-Moisture allows the movement of cells to start knitting together

Question 24

Emergent Phase: Collab & Nursing Care

Answer 24

-The face is highly vascular and subject to a great amount of edema -Arterial blood gases (ABGs) are measured to determine adequacy of ventilation & perfusion with inhalation or electrical injury -Physiotherapy is begun immediately to facilitate mobilization of the extravasated fluid back into the vascular bed -Maintains function, prevents contracture -Opioids are the drugs of choice for pain control -Analgesic requirements can vary tremendously from one patient to another -The extent and depth of burn may not be correlated with pain intensity -Lower extremity burns: risk for venous thromboembolism (VTE) -Low-molecular-weight heparin as prophylaxis

Question 25

Emergent Phase: Nutrition Therapy

Answer 25

Huge caloric needs – metabolism may ↑ 50-100%! -Inadequate calories & protein: malnutrition & delayed healing Early & aggressive nutritional support can: -decrease mortality risks & complications -optimize healing of the burn wound, and -minimize the negative effects of hypermetabolism & catabolism Enteral Feedings

Question 26

Acute Phase (Wound Healing)

Answer 26

-Diuresis from fluid mobilization occurs, and the client is less edematous -Bowel sounds return -Healing begins when: a.) WBCs surround the burn wound, phagocytosis occurs b.) Necrotic tissue begins to slough c.) Granulation tissue forms -Full-thickness burns must be covered by skin grafts

Question 27

Acute Phase: Collab & Nursing Care

Answer 27

The predominant therapeutic interventions in the acute phase are: -Wound care -Excision & grafting -Pain management -Physiotherapy & occupational therapy -Nutritional therapy -Psychosocial care

Question 28

Acute Phase: Collab & Nursing Care

Answer 28

GOALS -prevent infection -promote wound reepithelialization / skin grafting EXCISION GRAFTING

Question 29

Excision

Answer 29

-Eschar is removed down to the subcutaneous layer

Question 30

Acute Phase Nursing Care (Pain Management)

Answer 30

-Individualized & ongoing pain assessment & mgmt -One of the most critical functions a nurse performs on behalf of a patient with burn injuries

Question 31

Acute Phase Nursing Care (Physical & occupational therapy)

Answer 31

-To maintain muscle strength & optimal joint function

Question 32

Acute Phase Nursing Care (Nutritional Therapy)

Answer 32

-provide adequate calories & protein to promote healing

Question 33

Acute Phase Nursing Care (Psychosocial Care)

Answer 33

-support during the often lengthy, unpredictable, & complex course of care -SW & nursing play an important role

Question 34

Rehabilitation Phase (Restorative)

Answer 34

GOALS: -assist the patient in resuming a functional role in society -rehabilitation after functional and cosmetic reconstructive surgery MANIFESTATIONS: -new skin appearing flat & pink -then raised and hyperemic -itching occurs with healing Complications are skin & joint contractures and hypertrophic scarring: -mgmt includes positioning, splinting, and exercise to minimize this

Question 35

Rehabilitation Phase- Nursing Care

Answer 35

-Patient teaching using return demonstration (show-back) for dressing changes & ongoing wound care is essential to ensure good post-discharge wound healing -Continuous exercise and physical & occupational therapy cannot be overemphasized -Encouragement & reassurance are necessary for patient morale, attaining independence, and returning to pre-burn activities

Question 36

Alveolus: Gas Exchange

Answer 36

-Only the alveoli function in the exchange of the respiratory gases between the outside air and the blood

Question 37

Respiratory Failure

Answer 37

Respiratory failure is the state in which one or both gas-exchanging functions are inadequate -Either the amount of O2 transferred to the blood is insufficient -the amount of CO2 removed from the lungs is inadequate

Question 38

Respiratory Failure

Answer 38

-With inadequate gas exchange, the metabolic demands of the tissues are not met, and body systems begin to rapidly fail Hypoxemia: low O2 in blood -↓ partial pressure of O2 (PaO2 <60 mmHg) -↓ arterial O2 sats (SaO2) Hypercapnia: high CO2 in blood -↑ partial pressure of CO2 (PaCO2)

Question 39

Respiratory Failure

Answer 39

-Though respiratory failure is determined by the PaO2 & PaCO2, the major threat is the inability of the lungs to meet the oxygen demands of the tissues -May develop suddenly or over several days -Important to monitor trends in ABGs & SaO2 Initial Symptoms -Change in pt’s mental status -cerebral cortex is very sensitive to changes in oxygenation & acid-base balance -Tachycardia & mild hypertension -Heart Tries To Compensate

Question 40

Diagnostics

Answer 40

ABGS necessary to determine: -oxygenation (PaO2) & ventilation (PaCO2) status -acid–base balance Chest X-Ray Pulse oximetry (SaO2) Pulmonary Artery Catheter to Measure Pressures: -on the right side of the heart and cardiac output -mixed venous oxygen saturation

Question 41

Acid Base Imbalance: Respiratory

Answer 41

Acidosis: (hypoventilation) Increased CO2 in blood & increased carbonic acid -COPD -Overdose -Severe pneumonia Alkalosis: (hyperventilation) Decreased CO2 in blood / decreased carbonic acid -Hypoxia, PE -Anxiety, fear, pain -Septicemia, encephalitis

Question 42

Arterial Blood Gases- ABGs

Answer 42

PaO2: partial pressure of oxygen (75-100 mmHg) -Measures O2 pressure in blood -Reflects how well O2 is able to move from lungs to blood PaCO2: partial pressure of carbon dioxide (35-45 mmHg) -Measure CO2 pressure in blood -Reflects how well CO2 is able to move out of the body HCO3: bicarbonate (22-26 meq/L) -Chemical buffer that keeps the blood pH stable pH (7.4) -Measures hydrogen ions (H+) in blood

Question 43

Oxygen

Answer 43

-The fraction of inspired oxygen (FiO2) is the concentration of oxygen in the gas mixture -The gas mixture at room air has a FiO2 of 21%, meaning that the concentration of oxygen at room air is 21% (But, this is not the amt that participates in O2 gas exchange at the alveolar level) -For every litre of O2 flow, the FiO2 increases by 4%

Question 44

Oxygenation

Answer 44

-The primary goal of O2 therapy is to correct hypoxemia -O2 delivery: nasal cannula, face mask, Venturi mask Maintain PaO2 at 55-60 mmHg Maintain SaO2 at 90% * At lowest O2 concentration possible High O2 concentration** : adverse effects Intubated patients who receive >50% FiO2 for >24h are at risk to develop O2 toxicity

Question 45

Artificial Airways

Answer 45

Endotracheal Intubation (ET) -via mouth or tracheotomy Indications for Use -Upper airway obstruction -Secondary to burns, tumour, bleeding -Apnea -Respiratory distress -Inability to maintain the airway -ineffective clearance of secretions, altered or decreased level of consciousness

Question 46

Artificial Airways- Nursing Management

Answer 46

-Maintaining correct tube placement -Maintaining proper cuff inflation -Monitoring oxygenation & ventilation -Maintaining tube patency -Assessing for complications -Providing oral care & maintaining skin integrity, and -Fostering comfort and communication

Question 47

Mechanical Ventilation

Answer 47

-The process by which ventilation and oxygenation is supported or conducted by a machine Indications for Use -Apnea or impending inability to -Acute respiratory failure -Severe hypoxia, and, -Respiratory muscle fatigue

Question 48

Mechanical Ventilation: Types

Answer 48

Negative Pressure Ventilation Positive Pressure Ventilation (PPV) Non-Invasive (NPPV) - Continuous positive airway pressure (CPAP) -Bilevel positive airway pressure (BiPAP) Invasive -Spontaneous mode -Control mode

Question 49

Non-Invasive (NPPV): CPAP

Answer 49

-One pressure setting that is set -Keeps the airways & alveoli open during inspiration & expiration and prevents collapse

Question 50

Non-Invasive (NPPV): BiPAP

Answer 50

-Two pressure settings Inspiratory (I-PAP): PCO2 levels -Improves ventilation Expiratory (E-PAP): PO2 levels -Improves oxygenation

Question 51

Invasive (PPV)- Modes

Answer 51

-Respiratory therapists assume a key role in determining optimal ventilator settings SPONTANEOUS -The patient is able to determine the respiratory rate and the ventilator assists the patient CONTROL -The number of breaths, the size of the breaths, and the pressure generated are all controlled and preset

Question 52

Positive End-Expiratory Pressure (PEEP)

Answer 52

-a ventilatory setting in which positive pressure is applied to the airway during exhalation -the major purpose of PEEP is to maintain or improve oxygenation while limiting risk for O2 toxicity -the equivalent of E-PAP in non-invasive (NPPV)

Question 53

Acute Respiratory Distress Syndrome (ARDS)

Answer 53

-Sudden & progressive form of acute respiratory failure in which the alveolar-capillary membrane becomes damaged and more permeable by intravascular fluid The alveoli fill with fluid, resulting in: -severe dyspnea -hypoxemia refractory to supplemental O2 -reduced lung compliance -diffuse pulmonary infiltrates Despite supportive therapy, the rate of mortality from ARDS is approximately 50%

Question 54

ARDS- Progression

Answer 54

Injury or Exudative Phase -occurs 24-48 h -interstitial and alveolar edema Reparative or Proliferative Phase -Begins 1-2 weeks later -Lung is defined by dense, fibrous tissue Fibrotic Phase -Occurs 1 week after previous phase -Lung is completely remodelled with diffuse scarring and fibrosis -PROGNOSIS IS POOR at this stage

Question 55

ARDS PROGRESSION

Answer 55

-As ARDS progresses, it is associated with profound respiratory distress that necessitates endotracheal intubation and PPV -Severe hypoxemia, hypercapnia, & metabolic acidosis, with symptoms of target organ or tissue hypoxia, may ensue if without prompt treatment -The major cause of death in ARDS is MODS, often accompanied by sepsis

Question 56

ARDS Nursing Care

Answer 56

GOAL PaO2 of at least 60 mmHg & adequate lung ventilation to maintain normal pH CORRECT THE HYPOXEMIA -Pts commonly need intubation with mechanical ventilation because the PaO2 cannot otherwise be maintained at acceptable levels Positive End-Expiratory Pressure (PEEP) -It is a ventilator setting -Keeps alveoli open to maximize O2 exchange Prone Position -Demonstrated improvement in PaO2 -Changes the dynamic of ventilation