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Test #5 Burns Part 2
Cardiac
| Question | Answer |
|---|---|
| What is the #1 thing that a health care provider can do to prevent the spread of infection? | Wash Their Hands |
| What is the most effective way to treat wounds? | •Set up a sterile field •Prevent cross contamination by completing one section at a time If there are multiple wounds |
| What is a significantly increased risk for a patient who has an inhalation injury? | Pneumonia |
| The number one cause of burns in children is: | SCALD |
| What are the signs and symptoms of a superficial burn? | •Redness •Pain & Tender with touch •Dry Appearance •No Blisters •Healing 3-6 days without scarring |
| What are the signs and symptoms of a 2nd degree partial thickness burn? | Bright Red and Pink Moist and Shiny Blisters are present Very painful Heals in 10-21 days |
| What are the signs and symptoms of a 2nd degree Deep Thickness burn? | Red, White, Waxy Patches Minimal Pain to light touch May need grafting depending on scarring Heals in 3 Weeks |
| What are the signs and symptoms of 3rd degree Full thickness Burn? | White, Leathery, Tan, Dark brown, or Charred Black Skin is dry and Hard (Eschar) (Painless)-Nerve ending are destroyed Skin grafting needed Results in scarring and contracture |
| What are the signs and symptoms of 4th degree Deep full thickness burn? | •Destruction through skin and subcutaneous fat into the underlying fascia, muscle, tendon, and bone •Painless •Requires surgical intervention, including Fasciotomy, Escharotomy, Amputation & Grafting |
| What are the signs and symptoms of inhalation? | •Soot on face/ clothes •Singed eyebrows/ lashes •Black Sputum (Carbonaceous) •Sore throat-(cherry red), coughing, and hoarse •Intubation •May end up with a tracheostomy •End point = Stridor |
| Where do you Auscultate for an inhalation injury? | Over the Right and Left main stem bronchos. (This tells you if they are having good respirations) |
| What are the signs and symptoms for carbon monoxide stages 10% to 40% ? | •0%-10% Normal/Asymptomatic •10%-20% Mild Symptoms: A slight headache, nausea, and shortness of breath upon mild exertion. •20%-40% Moderate Symptoms: Throbbing headache (often severe), nausea and vomiting, dizziness, visual disturbances, and confusion. |
| What are the signs and symptoms for carbon monoxide stages 40% to 60% | •40%-60% Severe Symptoms: Profound confusion, extreme weakness, syncope (fainting/loss of consciousness, and tachycardia (fast heart rate). Coma and seizures •60% Lethal: Coma, respiratory failure, severe hypotension (low blood pressure), and death |
| 🔪 What is an Escharotomy? | •A emergency surgical procedure that involves making an incision (cut) through the rigid, non-elastic eschar (the tough, leathery, dead tissue) caused by a full-thickness (third-degree) burn. |
| What does an Escharotomy help prevent? | Loss of Blood flow to the limbs and difficulty breathing • Circumferential Limbs (Arm and Legs) : Compartment syndrome (Loss of Circulation) • Circumferential Chest/Torso: Respiratory Compromise (Can’t breathe) |
| What is a Fasciotomy? | Cutting (incising) the fascia tissue (-otomy) •Primarily used for compartment syndrome (including severe burns) to relieve acute pressure and restore circulation. |
| What is silver sulfadiazine cream for? | Controlling bacteria on the wound surface, it helps to prevent colonization and deeper infection |
| 🛑What are some Important Considerations for sulfadiazine cream!!! | •Not for all burns: It is not usually applied to first-degree burns •Side Effects: It can sometimes cause a temporary, localized burning sensation and may delay wound healing. •Allergies: It should not be used in patients with a known sulfa allergy |
| Never remove clothes on a burning patient: However, you may remove the clothes if: | The burn is due to Hot boiling water |
| Never Put Ice on a Burn because it causes: | Vasoconstriction, which can deepen the burn injury. It can also cause frostbite and hypothermia on large burns |
| What medications help burn patients for pain management? | • Opioids for Pain • Narcotics • IV analgesics |
| With Electrical Burns what do we worry about? | • You worry less about the visible skin burn and more about the invisible, extensive damage to internal organs and tissues along the current path • The “Lineman” (entry and exit wounds) charred debris on fingers • Ex.-Lightening and Electrocution |
| Scenario: Let’s say you were shocked, and she asks what is the biggest concern? | Cardiac: A current pathway often travels through the chest, disrupting the heart’s electrical conduction system. Which can cause Ventricular Fibrillation. • After a shock you must do EKG, And LABS. (To make sure that the heart is not damaged) |
| What are some Vascular changes resulting from burn injuries? | • Blood Flow decreases or ceases due to occluding blood vessels: The heat causes the blood vessels to swell shut or clot. • Vasoconstriction occurs • Blood Vessel thrombosis may occur causing necrosis |
| Fluid Shift (Primary Cause of Burn Shock) | •Initial constriction that shift the dilation and then it causes leakage It’s almost like you become the “Michelin Man” •Vasodilation combined with severe damage •Consequence (Burn Shock): decreased blood volume and severely decreased blood pressure |
| (Think Critically) What happens within the first 12 hours after a burn injury and can continue for up to 36 hours | Burn Shock (Hypovolemic Shock) |
| Fluid Imbalances After Burns | • Fluid and electrolyte imbalances occur as a result of the massive fluid shift and cell damage following a significant burn injury. • Immediately after the injury they go into a Hyperkalemic state, because after the injury calcium leaves the cell. |
| Why would a burn patient experience Hyponatremia? | They are “Hemo concentrated”, because they are dehydrated. |
| Now how would you know they are dehydrated?) What lab will you draw? | BUN |
| Fluid Remobilization occurs after? | 24-36 hours your dilation should start to fix itself. Everything should start to return to normal. |
| When you get to the diuretic stage of Fluid Remobilization, the fluids shift sending the patient into what type of imbalance? | Hypokalemia, cause of diluting the patient with the fluids. |
| What is a Curling Ulcer also known as a Peptic ulcer? | • Definition: It is an acute ulcerative gastro duodenal disease (ulcers that form in the stomach or duodenum) resulting from stress due to a major burn. • The patient is going to get an ulcer in 8-12 hours, in the very beginning they can start to bleed. |
| Reduced GI perfusion leads to: | Ischemia (lack of oxygen) of the GI lining. |
| • Clients with burns of 25% TBSA or who are intubated generally require ? | An NG tube inserted to prevent aspiration and removal of gastric secretions |
| Phases of Burn Injuries (Emergent) stage 24-48hrs (ADMISSION)!!!!! | • Upon Admission, you will issue a Tetanus Shot • Secure the Airway • Support circulation by fluid replacement • Keep comfortable with analgesics (Pain comfort) • Prevent infection through wound care • Maintain Body temperature |
| Upon Admission you should also get the patients’ health history. Why? Because: | • Diabetes (Impairs wound healing) and increases risk of infection • Hypertension (This will affect the ability to tolerate the massive fluid load requires for resuscitation and increases the risk of pulmonary edema) |
| Clinical Manifestations If patient lungs sound bad, it may be pulmonary. (Inhalation injury) or (Pulmonary Edema) | •They may go into shock if their pressure drops. •We will look at EKG. Everyone should get a EKG/5lead at the baseline of admission •Monitor oxygenation (Pulse Ox) . •Capillary Refill, helps detect impaired circulation for the need of a escharotomy |
| 24. “Remember” Kidneys are always the first to take a hit. (It's related to decreased renal blood flow) | • You want to make sure that the patient has enough urinary “Output” . You are looking for signs and symptoms of perfusion: |
| “Critical Thinking” Perfusion: What kind of Urine should the patient have? | Clear/Pale yellow. (Not dark, concentrated, or blood tea colored) |
| What’s the patient LOC? | •A well-perfused brain results in a normal LOC •Agitation, confusion, or decreasing LOC can signal hypoperfusion (shock). •Measure BUN, Creatine and NA levels to track electrolyte status |
| “Remember” in the first 24 hours the patient will not have enough Fluids. Fluids will be the primary mission. | •NEVER GIVE A DIURETIC due to hypovolemia, this would make it worse and plummet their blood pressure and can cause Acute Kidney Injury due to profound hypotension. •LACTATED RINGERS IS ISOTONIC (Just like normal saline) |
| In the Emergent Phase the Immediate problem is fluid loss, edema, reduced blood flow (fluid and electrolyte shifts) our goal is to: | •Secure airway •Obtain client’s pre burn weight to calculate fluid rates. Any calculations obtained after fluid replacement is started are not accurate. •Support circulation by fluid replacement •Keep the client comfortable with analgesics |
| Cardiovascular will begin immediately which can include shock (Shock is a common cause of death in the emergent phase in clients with serious injuries) You must obtain What at baseline? | EKG |
| Clients with burns of 25% TBSA or who are intubated generally require a | NG tube inserted to prevent aspiration and removal of gastric secretions |
| Nursing Care plan in the Emergent Phase. | • Decrease Cardiac Output • Deficient Fluid Volume (Because the patient is leaking) • Ineffective Tissue Perfusion • Ineffective breathing pattern |
| Acute Phase Key Goal is Prevent Complications of Immobility | You Have To Move The Patient! (Primarily to prevent complications related to immobility and pressure) -Prevent Pressure Ulcers |
| The primary goal in the Acute Phase is to increase mobility. you must: | Frequent turning (every 2 hours) relieves pressure on non-burned areas and deep pressure points (heels, sacrum, occiput), preventing tissue ischemia and the formation of pressure ulcers. •Preserve Joint Mobility (Prevent Contractures) |
| Pneumonia is a concern which can result in respiratory failure requiring mechanical ventilation | •Monitor for signs of infections |
| NURSING DIAGOSIS IN THE ACUTE PHASE | • Impaired skin integrity • Risk for infection • Imbalanced nutrition • Impaired physical mobility • Disturbed body image |
| What will be infection Signs? | • Vitals: This will show signs of infections • Drainage: Coming out of the wound. (Pseudomonas is a green color infection that happens with burns) • Altered level of consciousness • Gi dysfunction such as diarrhea, vomiting • Metabolic Acidosis |
| What Cream helps the prevention of MRSA? | Mupirocin (Bactroban)- Antibiotic Ointment that is giving in the nose to help with MRSA. (A lot of people have it in their nose) |
| NEED TO KNOW! – You CANNOT meet the Metabolic Demand. Why? | •They have issues with their stomach (ileus) •They have an NG Tube •The Caloric need for a patient with a major burn injury are indeed Astronomical. •Muscle Wasting: Rapid breakdown of lean body mass and skeletal muscle. |
| Impaired Wound Healing is caused by: | Lack of protein and calories compromises the body's ability to close the wounds. |
| What are the different grafts used to help with the patient skin recovery? | • Autograft: Tissue harvested from the patient's own body • Allograft: Tissue harvested from a genetically different member of the same species (Cadaver) • Xenograft: Tissue harvested from a different species (pig skin). |
| Discharge Instructions: • What can the patient eat? What will be their Diet? | Maintain a diet rich in protein (meat, dairy, beans, nuts) and calories to support wound healing and fight muscle wasting. |
| Discharge Instructions should include: | •What Is their wound treatment going to be? • Provide psychosocial support • When Do you call for HELP! • When is the next doctor appointment? • How would they Bath? “Reminder” Pressure garments are worn 23 hours a day |
| Pressure Garments should be worn: | 23 hours a day for at least a year |
| Remember: NO ASPIRIN!!!! This will cause: | Coagulation and will make the patient bleed |
| Circumferential Burns on chest or legs | •There is no circulation (due to tough leathery eschar not being able to expand), you have to check for pulses and perfusion of blood in the body |
| Circulatory S&S | • Loss of Distal Pulses (or diminished pulses via Doppler) • Delayed Capillary Refill (slow or absent perfusion) • Pain (especially with passive stretching) • Paresthesia (numbness/tingling) Intervention: Escharotomy |
| 36. What are the common signs and symptoms of Phlebitis? (Inflammation of the Vein) | • Hot red vein • Pain, Tenderness, or Swelling • Warm to Touch • A hard cord like feeling in the vein • Bulging and visible veins • Red itchy skin, that feels warm to touch over the veins • IV MUST COME OUT |
| 37. Infiltration (non-vesicant) Occurs when: | The catheter tip slips out of the vein & is leaking into the tissue |
| Signs and Symptoms of Infiltration include: | • Mounded • Skin at site feel cool to touch • Area may look pale and blanching • Swelling • No blood return Remember: Must Take IV OUT!! Immediately |
| 38. Extravasation (Vesicant) (The Bad Stuff) Occurs from: | The leakage of fluid or medication from a blood vessel into the surrounding tissues |
| Signs and Symptoms of Extravasation include: | • Swelling • Redness • Pain • Blistering • Numbness or Tingling • Warmth |
| Management & Complications of Extravasation: | • Stop the infusion • Do not flush • Gently aspirate • Remove the catheter (Don’t do immediately, you may have to give an antidote first) • Do Not Elevate the affected limb Note: If the IV meets resistance you must get rid of it |
| What is a Flare Reaction? | Is a common, localized, non-allergic skin reaction that can occur during or shortly after the intravenous (IV) administration of certain medications or fluids |
| Signs and symptoms of a Flare Reaction: | • Redness or Skin Rash • Swelling • Fever • Bone Pain • Immediate redness when IV push • Caused by local histamine release • May Subside in 30-90 min |
| 41. Warmers and Heat lamps: | Can be used to help keep the patient’s body temperature controlled. |
| Sensory Question: If a patient asks, will they ever look the same? The answer is: | NO. You will never look the same. |
| The primary concern in the emergent phase is | Hypovolemic Shock (Burn Shock) due to massive fluid shifts. (leakage) |
| Any patient with an electrical burn requires continuous | EKG monitoring for at least 24 hours. The current passing through the heart can cause fatal arrhythmia |
| Urine Specific Gravity: | This measures the concentration of particles in the urine and is a crucial, rapid indicator of fluid status. |
| Labs will be falsely elevated: | In the acute phase of burn shock (The first 24-48 hours), several lab values may appear elevated, but this is often a result of Hemoconcentration- This Is from the loss of plasma/water from the blood |
| Parkland Formula | Total Fluid (mL)= 4mL x Weight (kg) x % TBSA (second degree burn) |
| High Risk areas for Burns: | Face, Hands, Feet, & Perineurium |
| A 22 Guage needle for an IV is Preferrable for: | Elderly patients |
Created by:
LorrenIsrael