NURS 2208 Burns Study Guide Latest Updated,100% CORRECT

NURS 2208 Burns Study Guide Latest Updated Anatomical review: • Epidermis is the nonvascular outer layer of the skin o Skin cells originate from the basement membrane o Replaces every 30 days o Epidermis contains epithelial cells, which are responsible for regeneration of the skin • Dermis is the lower layer of the skin – is often called the true skin – o it houses blood vessels, lymphatic vessels, sweat glands, sebaceous (oil) glands, sensory and motor nerve endings o The Dermis can regenerate itself after external exposure, provides strength (connective tissue and fibers), nerves can feel heat/cold pain/pressure, capillary exchange of nutrients for waste occurs in the dermis. • Subcutaneous – adipose tissue and fascia (a band of connective tissue) o it lies above the muscles, tendons, bones, and internal organs o adipose tissue insulates, cushions, stores energy, and is normally white or yellow in color • Functions include: o Protection, Heat regulation, sensory perception, homeostasis regulation, Vit. D metabolism Goals in burns: • Prevention #1 (through education) • Instituting life saving measures (education on initial steps people can take outside of the hospital) • Prevention of disability and disfigurement through Fast, specialized & individualized care (no burn is the same) Types of burns: • Thermal (heat) o Direct contact with flame, flash scold, or contact with hot object ▪ Flame (gas stove) ▪ Flash (welding) ▪ Scold (hot object/liquid) ▪ Object: electric stove ▪ Severity depends on temperature and duration • Chemical o Contact with acids, alkalis, organics ▪ Acids (Clorox, bleach) ▪ Alkali (dry cement powder, oven and drain cleaners, heavy industrial cleaners)Harder to manage ▪ Organics (phenols, gasoline) - Creates burn then systemic process o #1 is to get ALL chemicals off! Must remove clothes! o Injury can continue up to 72 hours, does not stop at removal. o Why are alkalis harder to treat? When looking to neutralize alkalis, it is a harder process. (can’t add acids) • Electrical: o Results from intense heat generated by electrical current. o Nerves and vessels  great conductors of electricity ▪ Anoxia and death of tissues ensues. o 2 injury sites. Entrance and exit. From a nursing standpoint, we cannot determine which point is the entry/exit. o Can stop your heart, can produce fibrillation, dysrhythmias.  cardiac output & Perfusion!!!! ▪ We are not able to immediately assess other damage caused by the current. ▪ Heart monitor and EKG! Troponin, F&E, ABGs  Pao2, pH. • involuntary muscle contraction  causing fractures potentially  and can also cause skin tears. Also, falls? • Liver damage? Check lipid panel, Kidneys? Bun and creat. GI? Stools  blood? Hard stools? Dehydration? • Severity depends on voltage, level of tissue resistance, pathway it took, area affected, and how long contact. o Fatty areas offer the most resistance, opposed to nerves and blood vessels. (hands worst) • Myoglobinurea – Metabolic acidosis occurring from electrical injury, broken hemoglobin and rbcs pieces from tissue damage/death  leads to clots/obstruction  causing acute kidney injury  tints urine red. Most common in electrical injury, but can occur in any burn. FLUIDS help flush out! • Smoke Inhalation injuries o Hot air or noxious chemicals inhaled, causing damage to airway (trachea, oropharynx all the way to lung lining) o Huge predictor of mortality in burn pts. (if lining is damaged, no perfusion or gas exchange) (intubate) o Signs and symptoms ▪ Reddened area around nose/mouth, singed nose/facial hairs, sut in nares/mouth, sob, cough ▪ Smoke inhalation injuries can deteriorate up to 48 hours after injury. 100% humidified o2 o Firefighters, first responders, people who lock themselves in the closet during fires, etc. or open spaces • Lower airway o Trachea, bronchioles, alveoli. (think oxygenation)  longer around fire/enclosed area, more damage o Pulmonary edema 12-48 injuries after. Admit patient o SOB, Pulse ox, wheezing, crackles, singed facial/nose hair. ^RR, ^HR, restlessness, confusion, AMS • Upper airway o Mouth, oropharynx, larynx. ▪ Swelling may be massive and quick  AIRWAY! INTUBATION BEFORE SWELLING ▪ Early signs  difficulty swallowing, often clearing throat, ^ secretions mouth, drooling from inability to swallow. Start to hear stridor! Oh shit! • Metabolic asphyxiation o Oxygenation delivery impaired due to inhalation of CO or Hydrogen cyanide o CO is magnetic to hemoglobin, kicks O2 right off. ▪ Systemic hypoxia! (metabolic asphyxiation) – EMERGENT! ▪ Fix with 100% FiO2 humidified (usually intubated because other inhalation injury common) ▪ If it is JUST carbon monoxide, it is not a burn injury ▪ You will see anatomical damage to airway if you see metabolic asphyxiation • Remember  you may not see a physical burn. YOU CANT SEE IT ALL! Classification of burns: should they go to burn center? • Severity depends on depth of burn • Extent of burn in TBSA • Location of burn – Hands are less important than the face. • Patient risk factors  Infection, Nerve damage, shock. & pre-existing conditions. Diabetes? Heart failure? Depth of burns • Superficial partial thickness 1st degree o Involving epidermis – Erythema, blanching, slight swelling. 10-14 day heal time (ex. Sunburn) mild pain • Deep partial thickness 2nd degree o Blistering is the key differentiator. Red blistered painful and swollen moderate pain • Full thickness 3rd degree o Hair follicles and sweat glands destroyed. Burn site appears white or charred. Subcutaneous involvement (fat involvement) [may require graft] Contracture and functionality risk extreme pain • Full thickness 4th degree o Epidermis and dermis, plus damage to bones, tissues, tendons. NO PAIN. Requires grafting, flap or amputation Zone of burn injury • Zone of coagulation – no reversal • Zone of stasis – damage reversible, but very time sensitive o Can go DEEPER and wider with time o Need immediate fluid replacement and wound care • Zone of hyperemia o Outermost layer o Reddening and minor swelling due to vasodilation. Still injured This study source was downloaded by from CourseH on :07:23 GMT -05:00 • The more zone of coagulation, the worst • More zone of stasis, work FAST… or it’ll turn into coagulation • Think red light coag, yellow light stasis, green hyperemia Location • Face/neck/chest o Face and neck – Interference with breathing. Swelling can cause airway obstruction o Chest – limiting expansion due to scar tissue and burn injury o ***be concerned about inhalation injuries!!*** • Hands/feet/eyes/joints o Comes down to functionality • Ears/nose/perineum/buttocks o INFECTION RISK! o Ears and nose are thin and take a LONG time to heal • Circumferential burns o Around the whole limb, affecting blood flow to distal part! o Swelling can create obstruction! Check pedal pulses, cap refill, color, temp, sesation Risk Factors: • Heart – lower cardiac output, decreased compensatory rate r/t BP. bad perfusion = bad healing • Lung – Bad gas exchange = poor wound healing • Diabetes – poor vasculature… • ^ metabolic and calorie need – but no sugar! Bad wound healing • Drug and alcohol use  certain drugs vasoconstrict. Watch for withdrawl! Predisposed to infection, seizures. o Alcohol abusers – poor nutrition to begin with, body is already at an increased demand • Gerontologic patients o More comorbidities o Decreased mobility, decreased sensation o Hearing/vision issues (unable to hear or see fire warnings) • Pneumonia common complication, burn and graft donor sites take longer to heal, surgical procedures are not well tolerated Physiologic changes • Burns less than 20 TBSA in adults = primarily local response • Burns more than 20 TBSA in adults = local and systemic response o Cytokines – proteins secreted by the lymph cells affecting cellular activity and inflammatory response o Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction. From intervascular to interstitial ▪ This edema peaks 24-36 hours after injury ▪ Body starts to protect vital organs… leaves kidneys, etc with low perfusion – Elevated BUN and Creat, UO Pancreas – High blood glucose • LESS than 40, 25% of TBSA is a MAJOR burn • MORE than 40, 20% is major Body response • Elevated core body temperature – increases metabolic and fluid demand even more! Cool them down! Cooling blanket! • GI – Paralytic ileus. Curlings ulcers – causes ^ permeability  releasing gut bacteria into body ^ risk infection. Flank and back injuries, ^ pressure in abdominal cavity leading to compartment syndrome. • Metabolism o Initial phase – Decreased cardiac output, decreased O2 consumption, low metabolic rate (gets energy from muscles and stored fat), metabolic acidosis, ^ lactic acid  rhabdo causing muscle breakdown. o 5 days after, body kicks in to hypermetabolic state ▪ Body goes into overdrive, needs about 5k calories a day. Elevated temp, diaphoresis, ^HR, ^RR, ▪ ^ Glucose from hypermetabolic state – healing issue! Inhalation injuries: • Decreased o2, poor perfusion • Diagnosed with bronchoscopy • Look for alterations in ABG, black sut, necrosis in airway • Supportive measures o Protect airway, 100% humidified o2. Cough & deep breath often. Reposition patient, mobilize patient. ORAL CARE! o Listen to patient talk! Helps recognize deterioriation in that 48 hour period Carbon monoxide poisoning • CO replaces o2 on hemoglobin, causing hypoxia 200% more likely to hitch a ride on hemoglobin than o2 • Headache, weak and lethargy, confusion, AMS, N/V, gross motor function affected • At 50% carboxyhemoglobin level, patients start to get seizures, coma, etc • Treat carbon monoxide poisioning with 100% FiO2, in hyperbaric chamber for bad cases. • Carbon monoxide poisoning does not always accompany a burn injury Byproduct of fire • “cherry red cheeks” • Half life CO 3-4 hours, with 100% o2, 30 minutes. Mask or nonrebreather, 15 mins with hyperbaric chamber Plan for rehabilitation starts the day of the burn injury • Emergent phase, fluid resuscitation • Acute phase – Wound healing • Rehab – Physical and psychosocial Pre-hospital care: Scene safety, extinguish fire, remove burn substance off patient ABCCC – Airway, breathing, circulation, C-Spine, Cardiac Remove clothes and start oxygen and large bore IVs Good history  witness recount? Electrical injuries • Remove patient from contact with source Chemical injuries • Brush solid particles off skin, remove clothes, water lavage! Risk for further tissue destruction for up to 72 hours Small thermal burns • Cool within 1 minute to help minimize the depth of injury Large thermal burns • MAJOR burn causing systemic effect • No immerse in cool water or pack with ice because causes hypothermia and vasoconstriction! We want dilation! • Give clean dry blanket to keep patient warm Inhalation injury • First responders are trained to look for signs of inhalation injuries. o They are trained to intubate if needed Emergent Care • AIRWAY FIRST • Fluid resuscitation is begun (goal – within 1 hour) o Fluid shifts can happen for 24-36 hours o Normal fluid shift expected 30-50mL/hr. 200-400 for severely burned o 2 large bore IVs, Lactated ringers. • Fluid given en route must be calculated for! • Pain management - Morphine • Monitor I&O. Foley inserted, NG tube, EKG for electrical burn injuries • Patho o Neutrophils and monocytes accumulate at side of injury o Fibroblasts and collagen fibrils begin wound repair within 6 to 12 hours after injury o Immunologic ▪ Immune system is challenged when burn injury occurs. Skin barrier destroyed, bone marrow depressed, Circulating levels of immune globulins are decreased, WBCs develop defects Respiratory issues • Acute tubule necrosis – hemoglobin from rbc, myoglobin, etc breakdown travel to kidneys and block renal tubules o Fixed with fluid resuscitation Cardiac issues • Dysrhythmia • Cardio “Sludging” fixed with fluids PARKLAND FORMULA ***4 X (KG) X TBSA They get 1/2 of this total In the first 8 hours, 1/4 of total in next 8, 1/4 in the next 8. *** Given over 24 hours… example – 1,000mL  500mL first 8 hours, then 250 then 25