Medical-Surgical Nursing – Burns with verified solutions

A&P of Burn injury Immediate release of catecholamines and other mediators -Increased BP and HR, vasoconstriction, disrupted blood flow Increased capillary permeability -Edema anywhere including lungs, third spacing, low Na, hypovolemia, massive fluid shifts Decreased perfusion to GI system -Paralytic ileus, abdominal distention, Curling's ulcer Myoglobin and K released from cell damage ATN (kidney damage), high K Inflammatory response Immunosuppression, risk of infection/sepsis, loss of ability to sweat Increased demand on the metabolic system massive catabolism and increased need for calories, increased body temp, increased 02 demand RBC's hemolyzing causing hemoconcentration High HCT, High HGB, increased blood viscocity Thermal Burns Most common burn injury Flame, flash, scald, contact with hot objects Can require escharotomy Chemical Burns Acids, alkalis, organic compounds Alkalis are worse than acids Can also cause systemic symptoms Remove any dry chemical particles from the skin with a dry brush Dilute with water to stop causing tissue destruction Don't use neutralizing agents White phosphorus (used in meth) embeds in the skin and ignites when exposed to air Smoke/Inhalation Injuries Suspect for any burns of the head, neck, chest or a burn that occurred in an enclosed space Suspect if singed nasal hairs, hoarseness, coughing, airway redness, sore throat, carbon in sputum Major predictor of mortality in burn patients Lower airway injury is more likely from chemical exposure, can lead to pulmonary edema and ARDS Administer 100% humidified oxygen by mask, perform frequent respiratory assessment Carbon Monoxide Poisoning displaces oxygen on the hemoglobin molecule causing carboxyhemoglobinemia and hypoxia "Cherry red" skin, headache, n/v, unconsciousness or change in LOC and O2 sats Burns don't cause unconsciousness Give 100% humidified oxygen Electrical Burns Current produces heat causing extensive tissue damage, also damage to nerves and vessels Sparks can ignite clothing Can cause muscle contractions so strong that bones are broken and falls are caused (always assume they have cervical spine injury) Most damage is below the skin (iceberg effect) Can cause cardiac and renal problems Need EKG/cardiac monitoring ASAP Classification of Burns Depth (degree - 1st, 2nd, full thickness, etc) Extent in percent of TBSA (rule of 9s) Location Patient risk factors Partial-thickness, superficial (1st degree) -No blisters, red pink, dry, painful; only epidermis, heals in 5 days Partial-thickness, deep (2nd degree) -Blisters, red, shiny, wet, severe pain, some edema; includes part of dermis, heals in 1-2 weeks Full-thickness (3rd & 4th degree) -Lots of color variation - dry, waxy white, leathery, hard, no pain - all of epidermis and dermis -can NOT grow new skin, requires skin grafts Extent of Burn (Rule of 9s) Primarily for adults Add posterior and anterior sides of the body separately Perineum is 1, each arm is 4.5%, head is 4.5%, each leg is 9%, torso is 18% Don't include first degree burns when calculating, can be revised after edema resolves Location of Burns Burns to eyes, face, hands, feet and perineum are always considered serious Circumferential burns to chest/back or extremities are serious Other risk factors increasing burn classification older adults any pre-existing cardiovascular, respiratory or renal disease, diabetes, peripheral vascular disease Alcoholism or drug abuse Malnutrition Any additional injuries besides the burn Emergent burn injury resuscitative care, resolve immediate life-threatening problems, usually lasts 48-72 hrs -goal is to secure airway, maintain temp, and prevent hypovolemic shock Acute burn injury diuresis until wound closure, can take weeks to months -goals are to prevent infection, wound care, pain control, optimal nutrition and PT Rehab burn phase restorative; overlaps with the acute phase and continues after discharge; as early as 2 weeks or up to 7-8 months -begins when wounds are healed and patient is able to do self care -goals are to achieve maximal function, have psychological adjustment and gain independence Pre-Hospital Care >15% of body Stop the burning process (irrigate with water) If large, focus on ABC's Prevent hypothermia Never use ice (will vasoconstrict) Remove as much burned clothing as possible Remove rings and watches Identify chemicals Give 100% humidified oxygen EKG if electrical burn Emergent Phase (cardiovascular care) Cx - dysrhythmias, hypovolemic shock, circulation impairment, sludging, VTE, heart failure Tx - escharatomy if necessary to prevent circulatory impairment, fluid replacement, baseline EKG Acute Phase (cardio) Same complications as emergent phase Emergent Phase (respiratory care) Cx- edema/obstruction, constriction, pulmonary edema, resp infection Tx - CXR, ABGs, frequent assessment, early intubation, escharatomy if necessary, fiberoptic bronchoscopy, 100% humidified oxygen if not intubated, high fowlers, TCDB hourly chest PT, suction Acute Phase (Respiratory Care) Same complications as emergent phase, but also pneumonia Emergent Phase (Neuro Care) Should not have any neuro symptoms unless they have other injuries Acute Phase (Neuro Care) Cx - odd behaviors Tx - may need psych services Emergent Phase (Musculoskeletal Care) Assess for other injuries Start ROM Positioning is critical Acute Phase (Musculoskeletal Care) Cx - limited ROM, contractures Tx - stretch and move as much as possible, splints, ROM 3 times/day, ambulation, surgical release of contractures as needed Emergent Phase (Renal/Urinary Care) Cx - ATN, ARF Tx - fluid replacement (see F&E slide) maintain urine output at 30-50ml/hr, foley, watch BUN, creatinine, Na, specific gravity Acute Phase (Renal/Urinary Care) Foley needs to be removed Need to be 75ml/hr If cola colored urine, increase fluids Emergent Phase (Fluids & Electrolytes Care) Tx - 2 large-bore IV lines, arterial line, warmedLR, using the Parkland formula, hourly urine output (30-50ml/hr), also watch MAP and BP, no diuretics (instead adjust IV fluids to keep CO up) Acute Phase (Fluids & Electrolytes Care) Watch electrolytes closely as the body tries to achieve homeostasis Parkland Formula 2-4ml x kg x % TBSA = total fluid needed for 24hrs (multiply % TBSA as a whole number, not a decimal) LR only (crystalloids) Give 1/2 of total volume for 24 hrs in 1st 8 hrs, give the 1/2 of total volume for 24 hours in the next 16 hours Calculate hours from time of injury (not time of arrival) Avoid fluid boluses Don't change to decimal Emergent Phase (GI/Nutritional Care) Cx - paralytic ileus, Curling's ulcer, feed early (w/in hrs of injury) and aggressively Enteral preferred NG if paralytic ileus or intubated High protein, high calorie Supplements Prophylactic tx to prevent ulcers Test for occult blood