Burns Past Paper

**Burns** a\. Etiology: \(2) Non-thermal - electricity, chemicals and radiation. \(3) Effects of the burn depend on two factors. \(a) Extent of body surface burned, total body surface area (TBSA). \(b) Depth of burn injury. *Prevention of Burns -- Teaching people to proper use of appliances su...

**Burns** a\. Etiology: \(2) Non-thermal - electricity, chemicals and radiation. \(3) Effects of the burn depend on two factors. \(a) Extent of body surface burned, total body surface area (TBSA). \(b) Depth of burn injury. *Prevention of Burns -- Teaching people to proper use of appliances such as space heaters, electrical cords, wires, grills, water heaters, etc. can prevent injuries from burns.* Physiologic changes will occur withing the first few minutes to the first 12 -- 24 hours after the burn injury. b\. Pathophysiology: The greatest fluid loss will occur within the first 12 hours. \(1) [Emergent Phase, Stage 1 -] From onset of injury until the patient stabilizes (approximately 24- 48 a. Capillaries dilate and become hyperpermeable causing a shift of intravascular fluid into surrounding tissue (interstitial spaces). Cells become dehydrated. Capillary hyperpermeability lasts for about 24 hours. b. Result is edema and vesiculation (blistering). c. Blood pressure drops (hypovolemic shock). This is a major concern for up to 48 hours after a major burn. d. Blood flow to kidneys decreases resulting in acute renal failure. e. Foley insertion to monitor hourly output to ensure the best measure of intravascular fluid status. \(f) Burn Shock: characterized by: 1. Hypotension, decreased urine output, increased pulse, rapid and shallow respirations, and restlessness. 2. Most deaths from burns result from burn shock. a. Greatest concern for this stage is for circulatory overload because of fluid shifting back from the interstitial spaces into the capillaries. \(c) Circulatory overload can occur and increase the workload of the heart. around the upper chest, neck or face. Breathing difficulties may take several hours to occur. The cilia and mucosa may be damaged, and atelectasis can occur. \(a) Symptoms to look for: 1\) Hoarse voice, brassy cough, sooty sputum. 2\) Singed nasal hairs. 3\) Agitation, tachypnea, flaring nostrils, intercostal retractions. 4\) Erythema or edema of the oropharynx or nasopharynx. **Causes and Factors Determining Depth of Burn Injury (Table 43.5) Foundations & 21.3 of Critical Care.** a. Superficial (first degree): The epidermis is injured, but the dermis is unaffected. It heals in less than 5 days, usually spontaneously with symptomatic treatment. 1. Type - sunburn, low intensity flash flame, brief scald. 2. Appearance - dry surface without vesicles; minimal or no edema red; blanches on pressure and refills when pressure is removed; increased erythema (redness). \(3) Sensation -- painful. b. Partial thickness (second degree). Affects both the epidermis and the dermis. A superficial partial thickness burn can heal within 2 weeks with only some pigmentation changes but no scarring. A deep partial thickness burn may need debridement and skin grafts. It can take up to 3 weeks to heal and can leave some scarring. 1. Type - scalds, flash flame to clothes or skin, chemicals, ultraviolet light (sunburn). 2. Appearance - blistered, moist, mottled pink or reddened, blanches on pressure and refills. \(3) Sensation - very painful. c. Full thickness (third degree). All the layers of the skin (epidermis, dermis, and subcutaneous tissue) are destroyed and thus there is no pain. If not debrided, this type of burn leads to sepsis, extensive scarring, and contractures. Skin grafts are necessary because the skin cells are no longer alive to regenerate. This type of burn can also reach the muscle and bone. 1. Type - fire, contact with hot objects or liquids, flame, chemicals, electrical contact. 2. Appearance - tough with leathery eschar; white, charred, dark, brown, tan or red; [does not blanch] on pressure; dull and dry. \(3) Sensation - little or no pain, hair easily pulls out. 1\. Treatment of Burns a\. The [rule of nines] is used to determine the total body surface area (TBSA) burned. b\. Rule of Nines is calculated as follows: 1. Head 9% (anterior 4.5%, posterior 4.5%) 2. Each upper extremity 9% (anterior 4.5%, posterior 4.5%) 3. Front Torso 18% 4. Posterior Torso 18% 5. Each lower extremity 18% (anterior 9%, posterior 9%) 6. Perineum 1% c\. The rule of nines does not take into account the different levels of growth and is not accurate for children. 1\. Management of Burns a\. At the scene of the injury, the first priority is to prevent further injury. Ensure the scene is safe. Stop the burning process using the "stop, drop and roll" technique. Also remove clothing or other sources of the burn. [NOTE]: Laying the patient flat prevents the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. b\. Immediate assessment of the patient's airway is the first concern after the burn source has been eliminated. Establish and maintain the airway and administer oxygen. \(4) Early signs of CO poisoning include headache, nausea, vomiting, and unsteady gait. Treatment includes administering 100% oxygen. c\. Once the airway is open, bleeding must be controlled. \(2) Fluid resuscitation formula \(a) The Parkland formula for resuscitation is: \(b) Half of the fluid volume is given in the first 8 hours and the remaining half in the next 16 hours. Time is calculated from the time of the burn. d\. Monitor fluid intake and output every hour. This will require the insertion of an indwelling [Foley catheter]. This will ensure the best **measure** of intravascular fluid status. e\. A thorough physical assessment is completed every 30 minutes to 1 hour in the emergent phase. Assess circulatory status, which may be occluded due to eschar. f\. Insert a nasogastric tube to prevent aspiration. Patients with severe burns often develop a paralytic ileus as a result of trauma. g\. Administer intravenous morphine in small, frequent doses for pain control. h\. Provide tetanus immunization prophylaxis. Do not give intramuscularly because of poor absorption; instead give intravenous. i\. Acute phase. Begins when fluids shift back to the vascular circulation. This occurs approximately 72 hours after the burn. This phase may last from 10 days to months. \(3) Other complications are: \(a) Heart failure. \(c) Contractures. \(d) Paralytic ileus. \(7) Proper positioning and range of motion 1. **Care of Burns** **a. Traditional wound care involves the removal of the eschar that forms.** **(1) Eschar is a black leathery crust that the body forms over burned tissue.** **(2) Eschar can harbor microorganisms which cause infection and compromise circulatory status.** **(3) An escharotomy is often done to relieve the circulatory constriction.** **b. Daily debridement (removal of damaged tissue and cellular debris from a wound or burn to [prevent infection and to promote healing) and special cleansing support regeneration of the tissues.]** **c. The specific wound care method depends on the severity of the burn.** **d. The open method or exposure method may be used for burns of the face, neck ears, and perineum.** **(1) The area is cleaned and exposed to air. A hard crust forms and regeneration of tissue follows.** **(2) Proper positioning and range-of-motion exercises are vital.** **(3) Special bed equipment is needed to prevent the burn from touching the linens.** **(4) Room is kept warm and humidified. Chilling may be controlled by keeping the room temperature at 85 degrees F and providing lights or heat lamps for additional warmth. Humidity should be between 40%-50%.** **(5) Advantages of the open method.** **(a) Area can be observed more easily.** **(b) Movement is less restrictive.** **(c) Circulation is less restricted.** **(d) Exercises to prevent contractures can be done more easily.** **(6) Disadvantages of the open method.** **(a) Painful.** **(b) Body can chill more easily.** **(c) Potential for contamination.** **(d) Appearance is unattractive and may cause emotional distress.** **(e) Protective isolation is required.** **e. The closed (occlusive) method involves cleaning the burn, applying the prescribed medication, and dressing the wound as ordered.** **(1) Advantages of the closed method.** **(a) It protects the burn area from further injury.** **(b) It prevents contamination of the burn area.** **(2) Circulation checks are important with pressure dressings.** **(3) Administer analgesics 30 min prior to changing the dressing because it is a painful procedure.** **(4) Topical medications used to hasten healing and prevent infection vary. Topical administration is preferred because the capillaries are coagulated by the burn.** **(5) Burn care essentials include a lightweight dressing. A single layer of gauze covered with medication and a single wrap of Kerlix provide adequate coverage.** **(6) A new treatment for burns includes temporary skin substitutes made from a variety of materials.** 1. Skin Grafts a\. Skin grafts are used as soon as possible to cover full-thickness burns. b\. Four types of grafts may be used: \(1) Autograft uses the patient's own skin, which is transplanted from one part of the body to another. \(2) Allograft or homograft is human skin obtained from a cadaver. This is a temporary graft, which is used to cover a large area. It will slough away after approximately 1 week. It is used until the patient's own skin can be used for skin grafting. \(3) Heterograft or xenograft is obtained from animals, principally pigs. Like allografts, heterografts are temporary. \(4) Synthetic graft substitutes are alternative materials used to cover the wound and promote healing. This graft is also temporary. c\. Graft sites are a nursing challenge. \(1) Any movement that pulls at the graft area can dislodge the graft. \(2) Do not change dressings until ordered. d\. Donor site resembles a partial-thickness burn after the graft. \(1) Inspect for signs of infection (erythema and malodor) \(2) Pain is the primary complaint and should be treated. e\. The purposes of skin grafting are: \(1) Lessen the potential for infection. \(2) Promote healing. 1. Nutritional Considerations