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Complex II – Burns - Lecture notes 1

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Nursing Care- Complex Health Problems II (11-63-375)

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Academic year: 2018/2019
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University of Windsor

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COMPLEX II: MIDTERM #1 – BURNS Introduction  Burns are a leading cause of accidental injury and death not just in Canada but worldwide.  Although a vast number do not require hospitalization, severe burns can lead to significant morbidity and death BURNS…  Occur when there is injury to the tissues of the body caused by heat, chemicals, electrical current, or radiation  Injury → ↑blood flow → release vasoactive substances → ↑capillary permeability → fluid shifts SEVERITY IS DETERMINED BY…  Depth  Extent (TBSA)  Location  Age  Concomitant injury (what does this mean?)  Past health CLASSIFICATION OF BURNS  The treatment and prognosis of burn victims correlates with severity of their burns.  Reassessment of thermal burn size and depth is important particularly early in the management of patients with severe injuries  In the past, burns were defined by degrees:  first-degree,  second-degree,  third-degree  fourth-degree  The ABA (American Burn Association) now advocates categorizing the burn according to depth of skin destruction • Superficial partial-thickness burn • Deep partial-thickness burn • Full-thickness burn Third and fourth degree DEPTH OF BURNS  Superficial partial thickness – Involves the epidermis (eg. sunburn)  Deep partial thickness – Involves the dermis (d/t prolonged exposure) – Painful+++  Full thickness – Involves fat, muscle, bone – Not painful SUPERFICIAL PARTIAL THICKNESS DEEP PARTIAL THICKNESS (SECOND PIC “C” – PARTIAL THICKNESS BURNS DUE TO IMMERSION IN HOT WATER) FULL THICKNESS   Circumferential burns of the extremities can cause circulatory compromise  Clients may also develop compartment syndrome Added: ADMISSION TO THE BURN UNIT  Criteria: – Partial thickness burns greater than 10% of total body surface area in patients who are younger than 10 years or older than 50 years – Partial thickness burns over more than 20% of total body surface area in other age groups – Burns that involve the face, hands, feet, genitalia, perineum, or major joints – Third degree burns in any age group – Electrical burns, including lightning injury – Chemical burns – Inhalation injury – Burns in patients with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality rate – Any patients with burns and concomitant trauma in which the burn injury poses the greatest risk of morbidity or death – Burn injury in children at hospitals without qualified personnel or equipment to care for children – Burn injury in patients who will require special social, emotional or long term rehabilitative intervention ADDED: probably an FYI? CLIENT RISK FACTORS  Age: – Infants: poor defense mechanisms/immature immune system – Older adults heal more slowly than young adults  Pre-existing cardiovascular, respiratory, renal disease  Diabetes mellitus  Alcoholism  Drug abuse  Malnutrition  Concurrent fractures, head injuries, or other trauma PREVENTION  Home safety – Cooking – Elderly  Electrical storms  Abuse situations TYPES OF BURN INJURY  Thermal Burns  Chemical Burns  Electrical Burns  Smoke Inhalation Injury  Cold Thermal Injury THERMAL BURNS • Caused by flame, flash, scald, or contact with hot objects • Most common type of burn CHEMICAL BURNS • Result from tissue injury and destruction from necrotizing substances • Most commonly caused by acids • Alkali burns cause protein hydrolysis and liquefaction; may cause more damage • Can cause respiratory and systemic problems; eye injuries • Remove clothing/lavage • Tissue destruction may continue for up to 72 hours after a chemical injury ELECTRICAL BURNS • Result from coagulation necrosis caused by intense heat generated from an electrical current • May result from direct damage to nerves and vessels causing tissue anoxia and death • Severity of injury depends on the amount of: • voltage • tissue resistance • current pathways • duration of the flow of the current • surface • exit/entry wounds • Suspect fracture • Risks • Metabolic acidosis • Myoglobin → ATN • Rhabdomyolysis Inhalation injury below the glottis:  Usually chemically produced COLD THERMAL INJURIES  FROSTBITE  Rewarming is imperative PHASES OF BURN MANAGEMENT  Pre-hospital Care  Emergent (Resuscitative)  Acute  Rehabilitative PRE-HOSPITAL CARE  Remove the person from the source of the burn; remove clothing  If <10% TBSA cover with clean, cool tap-water dampened towel  If large: check ABCs  No cold water (WHY?)  Wrap in clean, dry sheet (WHY?) Chemical Injuries – Brush solid particles off the skin – Water lavage area; clean/sterile sheet/dressing Electrical Injuries – Remove from source – ABCs, C-spine, distal pulses, fractures Added:  We must remove the patient from source of burning. Removing clothing.  DON’T USE ICE. Will only worsen the damage to the tissue.  We want to wrap them in clean dry sheets because; after the damp towels go on FIRST we need to wrap with damp sheets over top of that to make sure they don’t lose any more fluids as well as reducing their chance of HYPOthermia because their body temperature will start to decrease very quickly in patient with burn over 10% (You know how you shiver when you have a sun burn and get goosebumps) PRIMARY SURVEY  Airway management  Breathing and ventilation  Circulation and cardiac status  Disability, neurologic deficit and gross deformity  Exposure Added: Exposure; do we need to cover up the burn? Remove clothing? Brush off debris? You need to expose the burn in order to determine how to proceed with care. EMERGENT PHASE  Is the period of time required to resolve the immediate problems resulting from burn injury  From burn onset to 5 or more days – Usually lasts 24-48 hours – The phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begin EMERGENT PHASE – PATHOPHYSIOLOGY  Fluid and Electrolyte Shift – Greatest threat is hypovolemic shock – Caused increased permeability → massive shift of fluids from vascular space into interstitial spaces  Fluid and Electrolyte Shifts – The net result of the fluid shift is intravascular volume depletion  Edema (increase capillary permeability to protein)  ¯ Blood pressure  Pulse  Fluid and Electrolyte Shift – Normal insensible loss: 30 - 50 mL per hour Severely burned client: 200 - 400 mL per hour  Fluid and Electrolyte Shifts – RBCs are hemolyzed by a circulating factor released at the time of the burn causing  Thrombosis – Elevated hematocrit (d/t plasma leakage → edema – Anemia  Fluid and Electrolyte Shifts – Na+ shifts to the interstitial spaces and remains until edema formation ceases – K+ shift develops because injured cells and hemolyzed RBCs release K+ into extracellular spaces  Inflammation and Healing – Neutrophils and monocytes accumulate at the site of injury – Fibroblasts and collagen fibrils begin wound repair within the first 6 – 12 hours after injury  Immunological Changes – Burn injury causes widespread impairment of the immune system Loss of Na, loss of albumin. We see: Hyperkalemia, Hyponatremia, decreased albumin, but HIGH hematocrit * Important to remember these imbalances EMERGENT PHASE - CLINICAL MANIFESTATIONS  Shock from pain and hypovolemia  Hypothermia  Blisters  Edema  Decreased urine output  Adynamic ileus/Abdominal compartment syndrome  Shivering  Altered mental status Added:  Shock – pain because of the severity  Hypothermia – warm air or concurrent heat exchange. Hydrotherapy in tubs.  Edema leads to compartment syndrome.  Abdominal compartment syndrome – is a deadly thing, causes necrotic bowels.  Urine output because fluid is shifting, BP is low, so kidneys aren’t working properly.  We don’t want them shivering because it increases their metabolic rate.  Monitor mental status because of decreased profusion to the brain. EMERGENT PHASE – COMPLICATIONS Cardiovascular System shock, arrythmias impaired circulation (gangrene) increased blood viscosity (gangrene) – Respiratory System Upper respiratory tract injury Mechanical airway obstruction and asphyxia Inhalation injury – Direct insult at the alveolar level – Interstitial edema – May not exhibit signs during first 24 hours – – Assess LOC; resp distress RX: 100% O2, high Fowler’s, DB&C, position, physio, suction Respiratory System Pneumonia Pulmonary edema  Urinary System Acute tubular necrosis (ATN) Added:  At risk for shock, burn shock, arrhythmias especially when their potassium levels are altered. Impaired circulation (gangrene) because they have high viscosity in blood which puts them at risk for thrombus.  Causes the most problems in 24 hours. Obstruction due to swelling or if they have inhaled something.  Asphyxia à basically means suffocation.  What does it mean if a patient has bilateral wheezes and the wheezes are no longer audible but there has been no interventions?  A: this is a bad sign. The airway is totally obstructed. No air is getting in. We need to look for “Soot” around the mouth. This patient would require a tracheotomy. (Think of episode in Greys anatomy when April forgot to check inside the mouth during her head to toe because she got distracted…The patients airway completely closed up and they had to do a tracheotomy right away and didn’t know why….April got fired after that –important to check inside the mouth!)  Pt might not have any signs but could deteriorate over time.  Myoglobin being clogged up and causing ATN and renal failure. EMERGENT PHASE - NURSING MANAGEMENT  Airway Management – Early nasotracheal or endotracheal intubation – Escharotomies of the chest wall – Fibre-optic bronchoscopy – Humidified air and 100% oxygen  Fluid Therapy – Parkland (Baxter) formula for fluid replacement – Crystalloid solutions: MOST NB 1st 24 hours for major burns – Colloidal solutions  Adequacy volume replacement determined by: - urine output (amount?) - systolic BP           o How to evaluate how much fluid we give is by their urine output, BP, HR, LOCW Wound care should be delayed until the patient has AIRWAY, BREATHING, CIRCULATION. Hydrotherapy à we need to put them in the tub. Sterile tub. They do this in order to do debridement Debridement à procedure to remove dead necrotic tissue. They have to remove this tissue in order for new tissue to be able to form. Primary goal is to close the wound as soon as we have ABC’s established. Usually will go to a burn unit in order to receive optimal care. Daily hydrotherapy (no longer than 20 mins – warm outside tub needs to be warm air to prevent hypothermia), washing patient with chlorohexadine, goal is to gently debride dead tissue while leaving the alive tissue under it, clean the area, then they apply topical antimicrobials to limit the bacterial proliferation, and fungal colonization. (silver sulfa) most commonly used topical agent. If patient is burned over 50% of body, they might have up to 4 nurses in the room while cleaning the patient to be able to reduce the amount of time that this patient has to be in the tub. After 24 hour period we need to worry about infection. Our skin is supposed to be our first line of defense against infection and with a burn that has been removed. Key thing is that topical ointment is directly absorbed by these tissues vs systemic that is absorbed by the body. % Body Surface burned, multiplied by 4 mL multiplied by their weight in kg. Half of that amount you get within the first 8 hours and the rest within the next 16 hours. (equals 24 hours) Need to know this formula!!! Will be asked to calculate this either over the first 8 hours or over 24 hours. DRUG THERAPY - Antimicrobial agents Topical agents – Silver sulfadiazine (Silvadene, Flamazine) – Povidone-iodine ointment – Systemic agents not usually used (WHY?) Added: Because it will be absorbed by the body and not directly to the tissues Acticoat – Silver sulfa coating on the inside. Cover burn with this and then with another dressing. Gauge over top to hold dressing in place. BIOLOGIC DRESSINGS  Skin from a biologically similar donor good for debriding eschar during the frequent changing of the biologic dressing  Protecting exposed granulation tissue for which donor sites are not yet available for autografting  Provide an effective cover for exposed healthy tissue beneath excision or other traumatic skin defects  Decrease evaporative water loss and exudative protein loss  Provide a convenient dressing that can be observed without additional therapy  Decrease pain and permit more extensive physical therapy  Xenograft (pigskin), Allograft or Autograft (for discussion on graft will follow) Added: Will eventually get sloughed off by the body, but helps protect during initial burn period. DRESSINGS – ALGINATES  Alginates-Highly absorbent, biodegradable dressings are derived from seaweed.  High absorption that is achieved via strong hydrophilic gel formation and minimizes bacterial contamination.  Alginate dressings maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue. – Nutritional Therapy Fluid replacement takes priority over nutritional needs. When bowel sounds return at 48-72 hours, oral intake can be initiated beginning with clear liquids. COLLAB CARE  Hypermetabolic state  Resting metabolic expenditure may be increased by 50% to 100% above normal; Core temperature elevated  Caloric needs: 5000 kcal/day  Early, continuous enteral feeding promotes optimal conditions for wound healing  Supplemental vitamins and iron Added:  Preventing contractures depends on how we position the patient.  No pillow under neck if they have burns on neck because they can get a contracture in that area.  Perineum clean and dry to prevent cross contamination from that area to the burn area. If they have burns in this area they might do a urostomy/ileostomy to prevent cross contamination from these two areas.  Blocks the short term memory prior to tubbing so that they don’t remember the painful procedure. The hydrotherapy is very painful for the patient so even the slightest amount of water running will cause a great amount of fear an anxiety. This is why we give them a sedative.  Burn has destroyed their barrier, they will require a tetanus shot.  When bowl sounds return they can go on clear fluids. Might require tube feeds, etc. ACUTE PHASE  Begins with the mobilization of ECF and subsequent diuresis  Concludes when the burned area is completely covered by skin grafts or when the wounds are healed (weeks-months) Added: Fluid starts shifting ACUTE PHASE – PATHOPHYSIOLOGY 1. Diuresis 2. Bowel sounds return 3. Healing begins 4. Necrotic tissue begins to slough 5. Formation of granulation tissue 6. A partial-thickness burn wound will heal from the edges 7. Full-thickness burns must be covered by skin grafts SKIN GRAFTS Surgeon harvesting skin  Autografts from the own patients body. Taking from another area of body if they aren’t burned all over body. They take the piece of skin and put it through a device to stretch the skin in order to cover the area. Grafted areas might form into the patient’s own skin, or sometimes it sloughs off Donor site after harvesting  Cadaver skin or pig skin. Needs to be tested for HIV, Hepatitis, etc. Healed Split – Thickness Skin Graft Mesh – skin from person themselves and put it through the machine and then covered with mesh. Application of Cultured Epithelial Autograft  Where they grow the patients own skin. Limited area of own skin due to burns. Cultured the skin and then autograph it onto the patient. ACUTE PHASE – CLINICAL MANIFESTATIONS  Partial-thickness wounds form eschar – Once eschar is removed, epithelialization begins – Expected to occur in 10 - 14 days – Full-thickness wounds require debridement ESCHAROTOMIES – DEEP BURNS  Away from main arterial and venous blood supply  Mid medial or mid lateral aspect of limb is used Added: Extremity compartment syndrome – from extensive edema formation. Usually no problems unless severe hypoxia occurs May see: Disorientation Combative behavior Hallucinations Delirium ICU psychosis syndrome: may need analgesics and antianxiety drugs  Musculoskeletal System – Decreased ROM – Contractures  Gastrointestinal System – Adynamic ileus – Curling’s ulcer  Endocrine System  Blood glucose levels: Stress diabetes  Insulin production  Hyperglycemia – – – – – – – Added:  Infection is a problematic complication in the acute phase.  We are aware that septic shock can occur.  The partial thickness can develop into the full thickness because it erodes further in the presence of infection.  Respiratory distress, pulmonary edema, electrolyte imbalances so we need to watch for cardiac arrhythmias  ICU psychosis syndrome – depending on their length of stay, etc.  Curlings ulcer is a stress ulcer related to a burn injury. Placed on a PPI.  Increased in corticosteroids – patients cortisol levels are high due to stress which increased their blood sugar levels which interferes with wound healing. Need to control their blood sugar levels. ACUTE PHASE – NURSING MANAGEMENT  Fluid Therapy NB!!: crystalloids and colloids  Wound Care – Daily observation – Assessment – Cleansing – Debridement – Appropriate coverage of the graft:  Fine-mesh gauze next to the graft followed by middle and outer dressings  Sheet skin grafts must be kept free of blebs  Excision and Grafting – Eschar is removed down to the subcutaneous tissue or fascia  Cultured Epithelial Autographs (CEA) – CEA is grown from biopsies obtained from the client’s own skin  Excision and Grafting  Artificial Skin  Life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable  Pain Management • Opioid every 1 - 3 hours for pain • Several drugs are given in combination Morphine with haloperidol Morhine with versed (midazolam) Morphine with valium (diazepam)  Physical and Occupational Therapy Exercise during and after hydrotherapy Passive and active ROM Compression Garments Custom fit splints  Nutritional Therapy Calculation of caloric needs by dietitian High-protein, high-carb foods Diet supplements Weigh regularly  Psychosocial Care Social worker Nursing staff Pastoral care Added:  Might need to give them albumin (Colloid)  Know the diff types of grafts.  Need to be monitored, we don’t want air bubbles in the dressings because this could make the graft slough off.  These drugs are often given prior to procedures since they are so painful. The goal is that the patient doesn’t remember the painful procedure.  Preventing contractures, aside from physical therapy, they might also use compression devices which keeps the skin tight and heavy to keep it smooth and pushed down to prevent the keloids (scarring) NON-PHARMALOGICAL STRATEGIES

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Complex II – Burns - Lecture notes 1

Course: Nursing Care- Complex Health Problems II (11-63-375)

23 Documents
Students shared 23 documents in this course

University: University of Windsor

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COMPLEX II: MIDTERM #1 – BURNS
Introduction
Burns are a leading cause of accidental injury and death not just
in Canada but worldwide.
Although a vast number do not require hospitalization, severe
burns can lead to significant morbidity and death
BURNS…
Occur when there is injury to the tissues of the body caused by
heat, chemicals, electrical current, or radiation
Injury → ↑blood flow → release vasoactive substances →
↑capillary permeability → fluid shifts
SEVERITY IS DETERMINED BY…
Depth
Extent (TBSA)
Location
Age
Concomitant injury (what does this mean?)
Past health
CLASSIFICATION OF BURNS
The treatment and prognosis of burn victims correlates with
severity of their burns.
Reassessment of thermal burn size and depth is important
particularly early in the management of patients with severe
injuries
In the past, burns were defined by degrees:
first-degree,
second-degree,
third-degree
fourth-degree
The ABA (American Burn Association) now advocates
categorizing the burn according to depth of skin destruction
• Superficial partial-thickness burn
• Deep partial-thickness burn
• Full-thickness burn
Third and fourth degree
DEPTH OF BURNS
Superficial partial thickness
–Involves the epidermis (eg. sunburn)

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