Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
25 Cards in this Set
- Front
- Back
|
CLASSIFICATION
Superficial (first degree) |
Epidermis
Erythema, mild discomfort Minimal tissue damage Pain resolves in 48-72 hrs No residual scarring Example – sunburn |
|
|
CLASSIFICATION
Partial thickness (second degree) |
Epidermis, varying layers of dermis
permeability plasma leakage Fluid lifts epidermis blister Exposure of sensory nerves pain Heals itself because some epithelial cells remain Minimal scarring Lots of cool water *Superficial Partial Thickness *Deep Partial Thickness |
|
|
CLASSIFICATION
Full Thickness (3rd or 4th degree) |
Epidermis, dermis destroyed with possible fat, muscle, bone destruction
Eschar - Leathery brown or black covering denatured protein/dehydration Destroyed nerve endings – painless Requires grafting |
|
|
SEVERITY CRITERIA
|
Minor
Deep Partial thickness < 15% BSA Full thickness < 2% BSA Moderate Deep Partial thickness 15% - 25% BSA Full thickness < 10% BSA (older child & <60) Major – requires a burn center Partial thickness > 25% BSA Full thickness > 10% BSA Respiratory tract, face, hands. feet, or perineum Age <2, >60 unless superficial burn Penetrating electrical; deep chemical burns Associated fracture or soft tissue damage Burns with concurrent illness |
|
|
SYSTEMIC RESPONSE TO MAJOR BURN
|
Cardiovascular
CO Hypovolemia Edema Respiratory Pulmonary edema ARDS Renal/GI Renal Failure Hepatic Disfunction Intestinal Infarction Hypermetabolism – 2-4 times higher Immune compromise |
|
|
HYPOVOLEMIA
|
48 – 72 hrs (emergent phase) just keep you alive and not going into shock and dying
Vasodilation fluid shift from vascular to interstitial spaces, capillary permeability Na and Protein (blisters) or, K+, increased H&H Fluid leaks into deeper tissues Hypovolemic shock (Protein & Na loss) - edema at site, dehydration in rest of body, not so much a loss of volume but a loss of fluid to interstitial space Hemoconcentration sluggish flow, micro-clots renal perfusion oliguria Metabolic acidosis Respiratory distress Hypovolemic shock Upper airway obstruction Laryngeal edema |
|
|
DIURETIC STAGE
|
Post fluid resuscitation
Fluid back to vascular space Increased renal flow with diuresis Potential for overload Electrolyte imbalance, decreased potassium, increase sodium Anemia, malnutrition, weight loss Curling’s ulcer – 60% of clients, occurs in the stomach, caused by poor perfusion and stress |
|
|
MANAGEMENT
Emergent Period Emergent Interventions (48 HR) |
First aid
Remove clothing / jewelry (especially rings due to swelling) Check pulses distal to the burn, compartment syndrome Cover wound, prevention infection/fluid loss Wrap patient to prevent heat loss Flush chemical burn with water unless it’s dry (brush it) Observe dysrrythmia, if electrical burn |
|
|
Pain relief
|
Gentle, minimal handling
No IM or SQ - pools in tissues, could cause overdose during diuresis effect, all iv, Narcotics - choice drug PCA or small, frequent doses (2-4 mg) |
|
|
FLUID REPLACEMENT
|
Body Fluid Replacement – start during first golden hour
Started within first hour Hypertonic salt, Electrolytes, Non-electrolytes Formulas used to estimate fluid replacement needs – (Parkland most common – 4ml/Kg/%TBSA burn)) Replacement in 3 eight-hour segments: First 8 hours = half 1/4 2nd and 3rd segments Assess overhydration / water intoxication, when urine is 30-50ml per hour we know that rehydration is reaching kidney, watch for overhydration Output adults (30-50ml/hr); adolescent (0.5ml/kg); infants /children (1- 2ml/kg) Assess hourly output Output no longer gauge for fluid replacement after diuresis starts (next stage) |
|
|
ACUTE PERIOD
End of emergent until burn heals |
Infection - #1 killer
Septicemia Pneumonia Renal failure |
|
|
ACUTE PERIOD
Infection control |
Loss of protective barrier, dysfunction of immune system, nutritional deficiency
Primary source - bacteria in hair follicles, sweat glands Culture nose, throat, wound, skin 2X/week Surgical asepsis Special care unit to exposure |
|
|
WOUND MANAGEMENT ACUTE
|
Cleaning and debriding of eschar, need healthy bed of tissue to put graft on
hydrotherapy, hosing, or spray table Assess S/S of sepsis Change in LOC – sometimes first sign Fever, tachycardia, tachypnea Abdominal distention – gut may have infarcted Paralytic ileus – quiet bowels, not passing gas, pain, n/v Oliguria – kidneys are affected |
|
|
WOUND TREATMENT
|
Non-surgical debridement
Mechanical – for smaller areas Hydrotherapy Manual removal of dead tissue and eschar Enzymatic Autolysis Topical enzyme agents (Santyl) Surgical Debridement for large areas |
|
|
Dressing Options
|
Standard - gauze
Biologic – temporary first then final is added Homografts (allografts – least chance of infection) – human, cadaver or autograft Heterogafts – pigskin Amniotic membrane Cultured skin Biosynthetic Synthetic |
|
|
Silver sulfadiazine (Sylvadene, Thermazene)
|
non toxic salt of silver sulfadiazine in water based cream, binds to bacterial cell membranes and interferes with DNA synthesis.
ADVANTAGES Painless, does not cause electrolyte imbalances, delays eschar separation longer than other drugs DISADVANTAGES absorbed into eschar less than other drugs, may cause rash or pain, not as effective for burns covering over 60% of body, not effective against pseudomonas INTERVENTIONS watch for signs on infections, allergic reactions causing drop in WBC's |
|
|
Collagenase (Santyl)
|
Topical enzymatic debriding agent, digests collagen in necrotic tissue
ADVANTAGES Painless, no s/e, quick debriding action, easy to apply, not harmful to healthy tissue, specific to only non-viable tissue DISADVANTAGES expensive INTERVENTIONS apply once a day, monitor wounds for infection, may be used with barrier dressing |
|
|
Mafenide acetate (Sulfamylon)
|
Soft, white, non staining, water based cream. Bacteriostatic action
ADVANTAGES Effective against psuedomonas, long shelf life, excellent in treating electrical burns, penetrates thick eschar, may use as a solution to wet down grafts or wounds. DISADVANTAGES May lead to infection, may cause metabolic acidosis, hyperpnea, and rash. When applied, may cause pain that lasts 30-40 minutes. INTERVENTIONS pre-medicate for pain before application, monitor blood gas and serum electrolyte levels, monitor for infection |
|
|
Nitrofurazone (Furacin)
|
Cream, solution, or water soluble ointment, or foam. Wide-spectrum antibacterial
ADVANTAGES effective against staph aureus and some other antibiotic resistant bacteria, causes neither pain nor maceration DISADVANTAGES Rarely causes contact dermatitis, cream is messy, may cause renal problems with use on excessive burns INTERVENTIONS Observe for signs of allergic reactions and signs of superinfection |
|
|
Gentamicin sulfate (Garamycin, Gentamar)
|
Available as a cream or solution for topical use, antibiotic action against organisms resistant to other drugs
ADVANTAGES Effective against Pseudomoas, doesn't cause pain DISADVANTAGES May have ototoxic and nephrotoxic effects, may result in resistance by certain organisms INTERVENTIONS Use with caution if pt has renal problems, monitor serum and urine creatnine clearance before and during treatment |
|
|
Polymyxin (B-bacitracin)
|
Topical cream, wide spectrum antimicrobial
ADVANTAGES Painless, can be used on the face, ban be placed on healed grafts to lubricate DISADVANTAGES May cause uticaria, burning and inflammation, does not penetrate eschar INTERVENTIONS Apply every 2-8hrs to keep areas moist |
|
|
GRAFT CARE
|
Covered with bulky dressing to avoid dislodging
Splints for immobilization & to maintain position Donor site may be covered with fresh mesh gauze (Xeroform) – heals in 2 weeks, very painful due to exposed nerve endings May need pain meds for donor site |
|
|
NUTRITION - ACUTE
|
Physiology
Increased metabolism from Stress Fever Fluid loss Infection Increased oxygen consumption Heat production Metabolism increased 2-4 times Caloric needs increased 3500 – 5000, may need to start tpn due to gut problems but change to po asap Vitamin B1 to metabolize protein Zinc for healing HAL until GI motility restored Oral or tube feed ASAP |
|
|
REHABILITATION
|
Mobility – Maintain as much function as possible to maintain a higher starting point for rehab
Therapeutic positioning Specialty beds, e.g. tilt beds to tolerate upright positioning Splinting to prevent contractures Increases with grafting, bed rest Physical therapy Occupational therapy Prevent scarring Controlled pressure – keeps scars thinner, better mobility and look better Elastic bandage, Jobst stockings Emotional Response Death, pain, disfigurement Prolonged hospitalization; Job security Lifestyle change; reaction of others Patient Education Emphasis on future Wound management S/S complications Use of pressure dressings Exercises, splinting, ADL Reconstructive surgery Re-socialization Table 71-11or 28-9 - Needs to be Addressed Prior to Discharge |
|
|
Impaired gas exchange
|
– huge issues, high priority
Airway obstruction – wheezing, stridor, hoarseness, cyanosis around the mouth are first signs, any burns around face, in the mouth, around the neck increase risk Pulmonary edema – during diuretic phase of emergent phase Intrapulmonary shunting / atelectasis / hypoxia Carbon Monoxide retention – cherry red lips or capillary beds because CO is attached to free hemoglobin as opposed to O2 Fluid volume excess Excessive fluid resuscitation |
