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burnz shriner
| Question | Answer |
|---|---|
| Burns in Children | |
| Burn injury is the leading cause of | death in children from the ages of 1 to 4yr |
| Burns are the second leading cause of | death in children from the ages of 5-14yr |
| 60% to 80% of all burn injuries occur | in the home, and are often carelessness |
| Phases of Burn Care Nursing | 3 -R.A.R. |
| Resuscitative (emergent) | 1-3 days watch for hypovolemic shock complication: dysrythmias <circulation, edema causing necrosis ischemia, gangrene, increased blood viscosity, upper airway r/t direct heat injury inhalation direct at alveoli r/t chemical fumes or smoke |
| Acute | wound healing, begins with mobilization of ecf fluid. acute tubular necrosis if blood flow decrease to kidneys |
| Rehabilitative | 20% burn=20 days in hospital,burns have healed pt able to perform most adl's 2wks-7 months? 1%burn=1 day in hospital! |
| Primary Survey | ABC + C-SPINE |
| dark oral nasal membranes | Airway |
| check ventilation, respirations, establish airway! | Breathing |
| check for pulse and regularity, elevate burned limb to decrease pain swelling | Circulation |
| 2nd story burning house or car accident? | C-spine immobilization |
| Initial Management? | stop the burning process! |
| remove ? | jewelry, watches, belts, |
| remove clothes? | they will melt to skin! |
| cover with ? | dry, sterile or clean sheets |
| Types of Burns | Chemical Flame Electrical Scald |
| Assessment Data? | 5 ITEMS... |
| TBSA involved,Depth of injury,Location of burn,Burning agent,inhalation injury | |
| Pre-burn medical statusAssociated traumaPresence/absence peripheral pulses, AGE | |
| Nursing Diagnosis? | |
| Impaired gas exchange r/T airway edema and/or inhalation of toxic gases/SMOKE | |
| Of the 12,000 fire deaths in the U.S? | 50% - 60% are due to inhalation injuries =0 |
| Assessment? | |
| Airway Assessment | |
| Patency and respiratory distress | |
| Extent of smoke inhalation? | 5 FACTORS |
| 1. Circumferential burns | |
| 2 Edema of face and neck | |
| 3. Singed hair, etc. | shave one inch post burn singe line |
| 4. Soot in mouth | white red or black |
| 5. Hoarseness | damage to vocal cords |
| Chest burns? | |
| closed space more apt to have resp injury :( | Closed space/Open space |
| Signs and Symptoms of Respiratory Distress | CIGS~WA |
| Cyanosis/pallor | <CIRCULATION |
| Irritability progressing to lethargy | |
| Grunting | |
| Weak cry | |
| Slowing of respiratory rate | HIGH INTIALLY |
| Apnea, gasping (late sign) | |
| Carbon Monoxide | |
| Colorless Odorless Gas | |
| CARBON MONOXIDE=200x Affinity for hemoglobin | KNOW! |
| Does not allow for O2 transport | MAY BE CHERRY RED...NOT BLUE! |
| Obtain a carboxyhemoglobin level if needed | <5% IS GOOD! |
| Intervention? | GIVE O2 ASAP! BREAK UP CO2 MOLECULES ANY ROUTE CHILD TOLERATES HOOD,MASK, UPRIGHT HIGH FOWLERS..100% HUMIDIFIED AIR.EVEN INFANTS. GIVE O2 ASAP |
| Evaluation? | ALWAYS CHECK TRACH WHEN PATIENT COMES IN FOR CLINIC VISIT TO ENSURE WHEN IT IS NOT OCCLUDED! MAITAIN AIRWAY IS FIRST PRIORITY WILL SUCTION SMOKE & DARK DEBRIS, TUBE MAY BE STAPLED TO NOSE? |
| Nursing Diagnosis? | Fluid volume deficit related to increased capillary,permeability and third spacing |
| Assessment? | |
| Clinical Signs of Burn Shock | <BP, > PULSE, WEAK PERI PULSES, <UO, > RR, POOR SKIN TURGOR, THIRST, > HCT R/T RBC DO NOT LEAK OUT OF BLOOD VESSELS IT INCREASES BLOOD VISCOSITY |
| Intervention ? | |
| Fluid Replacement | |
| 2 Large bore angiocath >15% TBSA | LARGEST POSSIBLE, INTRAOSSIUS IF NEEDED, CAN START IV IN BURN TISSUE, CETRAL & ARTERIAL INE >30% TBSA |
| Lactated Ringer’s | |
| Begin as soon as possible | FLUIDS |
| Resuscitation? | KNOW FORMULA! |
| Calculated resuscitation and basal requirements | |
| (4cc x kg x % burn) + (1500cc x m2) = cc/24 hrs | |
| Fluid Therapy? | ON TEST |
| First 24 hours postburn | |
| ½ in first 8 hours | 470 |
| ¼ in second 8 hours | 235 |
| ¼ in third 8 hours | 235 |
| Nasogastric Tube ?Foley Catheter? | CHECK GASTRIC RESIDUAL OFTEN R/T RISK OF PARALYTIC ILEUS, UO GOAL 30-50 ML/HR, 1ST URINE OUTPUT NOT RECORDED DONT KNOW HOW LONG IT HAS BEEN IN BLADDER |
| Evaluation | |
| Indication of Adequate Fluid Replacement | KEY INDICATOR |
| Urinary output - 50-100 ml/hr adults | ADEQUATE |
| 1 – 2 ml/kg/hr children | ADEQUATE |
| Sensorium - Clear, alert, responsive | |
| Pulse - < 120 per minute | |
| Blood pressure - Normal or elevated | |
| Absence of nausea and ileus | |
| Electrolytes within normal range? | |
| Nursing Diagnosis? | |
| Potential for infection related to altered skin integrity as evidence | |
| by thermal burn injury | |
| Assessment | |
| Size of the Burn Injury (TBSA%)? | |
| PALMER METHOD? | |
| Used to estimate smaller burns | |
| Patient’s palm is equal to 1% of their Total Body Surface Area | |
| (TBSA) | |
| DEPTH OF BURN? | |
| Partial Thickness vs Full Thickness | |
| reddened/blistered waxy/white | |
| painful less painful moist surface dry surface | |
| exhibits capillary no capillary refill | |
| refill requires grafting | |
| Assessment of Circulatory Compromise:? | |
| Pulse | |
| Pain | |
| Pallor | |
| Paresthesia | |
| Temperature | |
| Intervention? | |
| Non-Surgical Intervention | |
| Removes debris and loosens necrotic tissue | |
| Reduces surface bacteria | |
| Makes it easier to estimate the size and depth of injury | |
| Begins preparation of area for grafting if indicated | |
| Topicals | |
| Silvadene | |
| Bacitracin | |
| Eucerin | |
| Surgical Intervention | |
| Excision | |
| Mesh Grafts | |
| Sheet Grafts | |
| Cultured Skin | |
| Growth occurs in 2 - 3 weeks | |
| Covers larger area | |
| Wet dressing x 10 days | |
| More fragile | |
| Takes longer to establish blood supply | |
| In future – elimination of donor sites | |
| Evaluation | |
| Progression of healing | |
| Monitor for signs of wound infection | |
| Assess for signs of systemic infection-sepsis | |
| Nursing Diagnosis | |
| Alteration in comfort related to pain | |
| Assessment | |
| Nonverbal Cues | |
| Irritability | |
| Restlessness | |
| Lack of interest | |
| Loss of appetite | |
| Withdrawal | |
| Crying | |
| Inability to sleep | |
| Facial grimacing | |
| Increased pulse and respirations | |
| Attempts to stay in position of comfort | |
| Intervention | |
| Pain Management Interventions | |
| Medications | |
| Pain - Morphine, Tylenol with codeine, Tylox | |
| Itching - Benadryl, Atarax | |
| Sleep - Ambien, Chloral Hydrate | |
| Anxiety - Versed, Ativan, Precedex | |
| Surgical Dressing Change – Ketamine | |
| Relaxation techniques | |
| slow deep breathing relaxation | |
| Distraction | |
| music TV, video movies | |
| Family participation | |
| Evaluation | |
| Nursing Diagnosis | |
| Alteration In Nutritional | |
| Requirements Related To Hypermetabolism As Evidenced By Increased Caloric Needs | |
| Assessment | |
| Diet History | |
| Lab Data | |
| IgG | |
| Transferin | |
| Pre Albumin | |
| Total Protein | |
| Intervention | |
| Hourly urine output | |
| Administration of calculated maintenance fluids | |
| Supplementation of electrolytes, albumin and vitamins | |
| Evaluation | |
| Nutrition Labs | |
| Urinary output-hourly | |
| Monitor weight weekly | |
| Ability to meet caloric needs | |
| Toleration of tube feeding | |
| Rehabilitative | |
| Nursing Diagnosis | |
| Alteration in functional capabilities | |
| related to scar formation and positioning | |
| Assessment | |
| Plan | |
| Intervention | |
| Evaluation | |
| No splint is better than a poorly fitted splint | |
| Alteration in Body Image as | |
| Related to the Burn Injury | |
| Subjective Data | |
| Objective Data | |
| Intervention | |
| Support Systems | |
| Consistency | |
| Encouragement | |
| Evaluation |
Created by:
arich23
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