NCM 112 Burns PDF

NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN...

NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN Page | 1 Classification of Burns according to its Causes Thermal Burns. This can be caused by flame, flash, scald or contact with hot objects. Chemical Burns. This results from tissue injury and destruction from acids, alkalis, and organic compounds. Acids are found in many household cleaners like hydrochloric, oxalic, hydrofluoric acid. Alkalis are found in oven and drain cleaners, fertilizers, and heavy industrial cleaners. Organic compounds include phenols and petroleum products, phenols are found in chemical disinfectants, while petroleum products are found in creosote and gasoline. Smoke and Inhalation Injury. The three types are: RN 1. Carbon monoxide poisoning 2. Inhalation injury above the glottis. This is due to inhalation of hot air, steam or smoke. Mucosal burns , AN and mechanical obstruction of the airway can occur. 3. Inhalation injury below the glottis. This is related to the duration of exposure to smoke or toxic fumes. Clinical manifestations of pulmonary edema, then ARDS may appear 12 to 24 hours after the burn. ,M Electrical Burns. This is due to the intense heat generated from electric current. Contacts with electric no current can cause muscle contractions strong enough to fracture long bones and vertebrae. All patients with electrical burns should be considered at risk for a potential cervical spine injury because most electrical ia injuries occur when the victim is elevated above the ground (e.g., during work as utility pole lineperson). ar And a fall occurs. Cervical immobilization should be used during transport. Electrical injury puts the patient at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria, which can M lead to acute tubular necrosis (ATN). The electric shock event can cause immediate cardiac standstill or o- fibrillation. CPR should be initiated immediately. Radiation Burns. May be due to excessive exposure to sunlight or from exposure to ionizing radiation as tin cancer treatment. Cold Thermal Injury. This is also called frostbite. en Common Places and Causes of Burn Injury ol.T 1. Occupational Hazards Hot water heaters set higher than 140°F (60°C) Tar Hot grease or liquids from cooking M Chemicals le Hot metals 3. General Home Steam pipes el Combustible fuels Gas fireplaces ch Fertilizers, Pesticides Open space heaters Electricity from power lines Frayed or defective wiring Radiators (home, automobile) Ri Sparks from live electric sources Improper use of outdoor grills 2. Home and Recreational Hazards: Kitchen / Bathroo Multiple extension cords per outlet Pressure cookers Carelessness with cigarettes or matches>> Microwaved food Improper use/ storage of flammables (gasoline, kerosene) The lecture notes are provided exclusively for personal use and study purposes within the context of our course. Any form of reproduction, distribution, or sharing of the lecture notes, without my express written permission, is strictly prohibited. -Richelle M. Tolentino-Mariano, MAN, RN NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN Page | 2 Types of Burn Injury and Risk Reduction Strategies 1. Flame Never leave candles unattended or near open windows/ curtains Encourage use of child - resistant lighters. Install smoke / carbon monoxide detectors Encourage use of home fire exit drills Never use gasoline or other flammable liquids as accelerants RN Never leave hot oil unattended while cooking. Do not smoke in bed or if very tired and likely to fall asleep. , AN 2. Electrical Avoid and/or repair frayed wiring. Ensure electrical power source is shut off before commencing repair. ,M Wear protective eyewear and gloves when conducting electrical repairs. no 3. Scald Lower hot water temperature to the "lowest point" or 120°F/ 40°C ia Utilize "anti-scald" devices with showerhead or faucet fixtures. ar Supervise bathing with small children, older adults, or anyone with impaired physical movement/ physical sensation/judgment. M After running the bath water, check the temperature with your hand or bath temperature. o- Exercise caution when microwaving food/beverages. tin 4. Chemical Store chemicals safely in approved containers and label appropriately. en Ensure safety of workers handling chemicals (education, protective eyewear, gloves, masks, clothing). ol Classification of Burns according to depth of skin involved:.T First degree. Involves the epidermis; reddish, intact skin; painful. Second degree. Involves the dermis; moist surface; with blisters; painful. M Third degree. Involves the subcutaneous layer; pearly white; no pain. le Fourth degree. Involves the muscles and bones; blackish or charred; no pain. el Note: First- and second-degree burns are partial - thickness burns; third and fourth-degree burns are full - thickness ch burns. Ri The Stages of Burns 1. The first stage of burns Shock Phase or Fluid Accumulation Phase or Emergent Phase. It occurs during the first 48 hours post - burns. Fluid shifts from intravascular compartment to interstitial compartment (IVC to ISC). This leads to generalized dehydration. Hypovolemia occurs due to plasma loss. This causes decreased cardiac output and fall of BP. The lecture notes are provided exclusively for personal use and study purposes within the context of our course. Any form of reproduction, distribution, or sharing of the lecture notes, without my express written permission, is strictly prohibited. -Richelle M. Tolentino-Mariano, MAN, RN NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN Page | 3 Hemoconcentration, increased hematocrit. Plasma is lost into the interstitial compartment (ISC). Oliguria. This is due to decreased renal tissue perfusion, decreased release of ADH and aldosterone. These are the body's responses to hypovolemia. Hyperkalemia and hyponatremia. This results from release of potassium from damaged cells; sodium is trapped in the edema fluids (ISC). Metabolic acidosis. This results from accumulation of metabolites, hyponatremia and hyperkalemia. Primarily, it is due to hyponatremia. Since sodium is unavailable because it is trapped in the edema fluids, bicarbonate produced by the kidneys will be excreted. RN 2. The second stage of burns Diuretic or Fluid Remobilization phase. , AN This occurs after 48 hours post burns. Fluid shifts from interstitial compartment to intravascular compartment (ISC to IVC). Hypervolemia, hemodilution and decreased hematocrit occur. This is due to fluid shift from ISC to IVC. ,M Diuresis. This is due to increased renal tissue perfusion, decreased ADH and aldosterone secretion. Hypokalemia, hyponatremia. Potassium moves back into the cells; sodium is still trapped in the edema no fluids. Metabolic acidosis. Decreased sodium levels excretion of bicarbonate by the kidneys. cause ia 3. The third stage of burns ar Recovery Stage. M This occurs on the 5th day, onwards. The following problems occur during this time: o- ○ Hypocalcemia.This results from loss of calcium in the exudates. It is also due to utilization of calcium in the granulation tissue (scar) formation in the areas of burns. tin ○ Negative nitrogen balance. In stress like burns, there is increased protein catabolism. Protein demands are increased for healing and protein intake may be inadequate. en ○ Hypokalemia. Potassium has shifted back into the cells, serum levels are decreased. ol The first aid interventions for patients with burns: Stop the burning process.T 1. Immerse the affected part in cold water. 2. "Drop and roll." Advise the client to drop and roll on the ground if clothing is in flame. To smother the M flame. le 3. Throw a blanket over the client to extinguish the flame. This cuts off the source of oxygen from the environment and the flame will spontaneously be extinguished. el 4. If the hands are involved, remove the jewelry. Jewelries are metals and they may be superheated, ch causing further tissue damage. They may serve as a tourniquet once edema of the hands and fingers occur. Ri The priority actions in case of fire are as follows: R-emove the patient A-ctivate the fire alarm C-onfine the fire. E-xtinguish the fire The lecture notes are provided exclusively for personal use and study purposes within the context of our course. Any form of reproduction, distribution, or sharing of the lecture notes, without my express written permission, is strictly prohibited. -Richelle M. Tolentino-Mariano, MAN, RN NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN Page | 4 To use the fire extinguisher, do the following: P-ull the pin A - im at the base of the flame S-queeze the handle S-weep from side to side Interprofessional collaborative management for the patients with burns include the following: RN 1. Promote respiratory function. Assess for sooty sputum and singed hair in the nose and eyebrows. (Singed hair is stiff and rigid burnt hair). , AN Establish an open airway. Administer oxygen therapy. ,M 2. Promote fluid - electrolyte and acid-base balance. Assess the following parameters: Vital signs no Urine output Central Venous Pressure (CVP) ia Level of Consciousness Weight ar Percentage of Burns M NOTE: The vital changes in dehydration are as follows: weight loss, decreased urine output, decreased CVP, and o- decreased level of consciousness. Changes in vital signs are as follows: elevated body temperature, increased pulse rate, rapid respiratory rate, low blood pressure (due to decreased plasma volume). tin ✓ The Rule of 9's for determining percentage of burns en ol.T M le el ch Ri The lecture notes are provided exclusively for personal use and study purposes within the context of our course. Any form of reproduction, distribution, or sharing of the lecture notes, without my express written permission, is strictly prohibited. -Richelle M. Tolentino-Mariano, MAN, RN NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN Page | 5 3. Relieve pain. Administer Morphine Sulfate per IV as prescribed. Monitor the client for respiratory depression. Have Narcan (Naloxone) readily available (this is the antidote of narcotics, if respiratory depression occurs). Initially, medications are given IV because of sluggish blood flow (increased hematocrit) during the first 48 hours post- burns. Use bed cradle to relieve pressure from the top sheet and to prevent sticking of exudates to the top sheet. Avoid exposure of affected areas to draft. Sudden gush of wind causes hypersensitivity of exposed nerve RN endings. Close the door of the client's room. 4. Prevent infection. Practice Asepsis. Handwashing is the most important practice to prevent spread of microorganisms. , AN Implement reverse or protective isolation. Administer Tetanus immunization. There is high risk of tetanus infection in burns. If history of tetanus immunization cannot be obtained, or the patient had not received booster dose for the last five years, ,M administer Immune Globulin. Irrigate affected area with normal saline (NS) solution. no 5. Maintain adequate nutrition. Do not give oral fluids for the first 48 hours. To prevent paralytic ileus, gastric dilatation and water ia intoxication. SNS stimulation causes decreased gastric motility that results to gastric dilatation; causes ar decreased peristalsis that results to paralytic ileus. Increased ADH secretion causes water retention. Provide high 1 calorie, high - carbohydrate, high protein diet. High-calorie, high carbohydrate diet M provides adequate source of energy. High protein diet promotes healing and tissue repair. o- Provide diet rich in Vitamins A, B and C. Vitamin A maintains skin and mucous membrane integrity. Vitamin B enhances metabolism. Vitamin C increases resistance to stress and infection.. tin 6. Provide wound care. The different methods of wound care: en a. Open method. After application of the topical antibiotic, the area is left exposed. This is applicable in extensive body burns. ol b. Semi - open method. The wound is covered with a thin layer of sterile gauze after application of topical.T antibiotic. c. Closed method. The wound is covered with a thick layer of sterile gauze or with occlusive dressings M after application of topical antibiotic. No two burn surfaces should be allowed to touch; touching can le promote webbing of digits, contractures and poor cosmetic outcome. This is indicated in burns of the hands. Apply dressings with the fingers separate from each other to prevent contracture deformities. Apply el splint on the hand with the fingers curbed to allow flexion-extension exercises of the fingers. This will also ch prevent nerve damage in the fingers and prevent hyperextension deformity of the fingers. Ri The antimicrobials used in burns: Furacin (Nitrofurazone) ○ Apply 1/16 inch film directly to the burn area. ○ Side effects: rash, contact dermatitis. Sulfamylon (Mafenide Acetate) ○ Apply 1/16 inch film directly to the burn area. ○ Administer analgesic prior to application of the medication. It causes local pain. The lecture notes are provided exclusively for personal use and study purposes within the context of our course. Any form of reproduction, distribution, or sharing of the lecture notes, without my express written permission, is strictly prohibited. -Richelle M. Tolentino-Mariano, MAN, RN NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN Page | 6 ○ The medication may (usually manifested by hyperventilation). cause ○ Other side effects may include rash, bone marrow metabolic acidosis depression, and hemolytic anemia. Silvadene (Silver sulfadiazine) ○ Apply 1/16 inch film. ○ It does not cause acidosis. ○ Side effects are as follows: rash, leukopenia, nephritis. ○ Monitor complete blood count (cbc), especially the white blood cells (wbc) level. RN Silver Nitrate ○ Apply silver nitrate to the dressing; do not apply directly to wounds, cuts or broken skin. , AN ○ It stains anything with which it comes in contact. Discoloration is not usually permanent. Hydrotherapy ,M It is done to remove debris, improve circulation, relieve pain, promote healing, improve muscle tone, and prevent contractures. no Administer analgesic 15 to 30 minutes before hydrotherapy to promote comfort. Immersion into the water may initially cause pain. ia Debridement ar To remove necrotic tissues from the area of burns. It may be surgical or mechanical debridement. M Mechanical debridement is done by wet-to-dry dressings. To do wet- to- dry dressings, do the following o- steps: 1. Wash hands. tin 2. Wear clean gloves, remove soiled dressing. 3. Remove gloves and confine soiled dressing within the gloves. en 4. Wear sterile gloves, apply sterile dressings over the area, pour sterile NS solution over the dressing. 5. Cover the moist dressing with dry dressings (gauze, sponges, or absorbent pads). To maintain moisture of the ol wet dressing..T 6. Change the dressing as it becomes dry (or just before) to remove the debris. As drying occurs, wound debris and necrotic tissues are absorbed into the gauze dressing by capillary action. M (Note: If you are using a sterile container with dressings, then pour sterile NS into the dressings first before dealing le with the soiled dressings). el Skin grafting ch To improve appearance of affected area. 1. Isograft or syngeneic graft. The donor site comes from an identical twin. Ri 2. Autograft. The donor site comes from the self. 3. Homograft or allograft. The donor site comes from another human being. 4. Heterograft or xenograft. The donor site comes from an animal, e.g., pigskin. This is temporary. Care of the Graft Site ○ Elevate and immobilize the graft site. ○ Keep site free from pressure. ○ Avoid weight bearing. The lecture notes are provided exclusively for personal use and study purposes within the context of our course. Any form of reproduction, distribution, or sharing of the lecture notes, without my express written permission, is strictly prohibited. -Richelle M. Tolentino-Mariano, MAN, RN NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS, ACUTE AND CHRONIC NCM 112 | BURN Page | 7 ○ Cleanse the graft from exudates to prevent infection and prevent graft adherence. ○ Monitor the graft site for signs and symptoms of infection like foul- smelling drainage, fever, elevated wbc, hematoma, or edema in the area. ○ Instruct the patient on the following: Lubricate healing skin with cocoa butter lotion. Protect affected area from sunlight. Use splints and support garments as prescribed. RN 7. Promote G.I. support. To prevent stress ulcer (Curling's ulcer). Insert NGT as indicated. Administer antacids, histamine receptor blockers as prescribed. , AN 8. Fluid Replacement. To prevent hypovolemic shock. Types of fluid replacement ,M a. Colloids: blood, plasma expanders (e.g. Hetastarch) b. Electrolytes: Lactated Ringers (LR) no c. Non-electrolytes: Dextrose 5% in water (D_{5}*W) ia Baxter and Parkland Formula (Crystallized Resuscitation) ar 4mls. LR x weight in kg. x % of burns M Allocation of fluid replacement for the first 24 hours: o- 1st 8 hours: 50% tin 2nd 8 hours: 25% 3rd 8 hours: 25% en Example: A client weighs 90 kg and the percentage of body burns is 22%. ol Total Volume of Fluid Replacement: 4 mls x 90 kg. x 22%= 7,920 mls..T M 1st 8 hours: 50% = 7,920 mls. X 0.50 =3,960 mls. le 2nd 8 hours: 25%= 1,980 mls. el 3rd 8 hours: 25%= 1,980 mls. ch 9. Rehabilitation Ri The priority goal of rehabilitation among burns clients is to prevent or minimize scarring. The patient may wear an anti - scar garment for 6 months. Other goals are to prevent contractures, promote activity tolerance, and improve body image and self-concept. The lecture notes are provided exclusively for personal use and study purposes within the context of our course. Any form of reproduction, distribution, or sharing of the lecture notes, without my express written permission, is strictly prohibited. -Richelle M. Tolentino-Mariano, MAN, RN