III. BURNS A.

Occurrence: The risk of death increases in the very OLD and the very YOUNG Where do most burns occur? HOME, CURLING IRONS, IRONS, STOVES, WATER HEATER B. Pathophysiology: After a burn many different pathophysiology changes occur. 1. Why does plasma seep out into the tissue? Increased CAPILLARY permeability (VESSELS LEAKING) 2. When does the majority of this occur? FIRST 24 HOURS DUE TO FLUID VOLUME DEFICIT 3. When does the pulse increase? Anytime youre in a FLUID DEFICIT , the pulse will INCREASE 4. Why does the cardiac output decrease? Less VOLUME to pump out. 5. Why does the urine output decrease? Kidneys are either trying to HOLD on to fluid or they arent being PERFUSED. 6. Why is epinephrine secreted? Makes you VASOCONSTRICTION, shunts blood to vital organs 7. Why are ADH and aldosterone secreted? Retain SODIUM & WATER with aldosterone and Retain WATER with ADH Therefore, the blood volume will go UP. C. Miscellaneous Information: 1. Airway Injury: What is the most common airway injury? CARBON MONOXIDE poisoning Normally, oxygen binds with HEMOGLOBIN Carbon monoxide travels much faster than oxygen. Therefore, it gets to the hemoglobin first and binds.Can oxygen bind now? NO, NO PLACE FOR IT Now the client is HYPOXIC. Tx: HYPOXIA

From this information, do you think it would be important to determine if the burn occurred in an open or closed space? CLOSED SPACE, INHALED MORE CARBON MONOXIDE When you see a client with burns to the neck/face/chest you had better think what? AIRWAY, UPPER BODY BURNS BREATHING PROBLEMS OCCUR *What might the physician do prophylactically? ET TUBE FIRST TO PREVENT SWELLING. 2. Classification of Burn Injury: A client is burned over 40% of their body. How do you think this is determined? RULE OF NINES Estimate of Total Body Surface Area A common formula is called the RULE OF NINES *TESTING STRATEGY* Least invasive first D. Tx: Clients with burns > 20-25% TBSA 1. Fluid Replacement: One of the most important aspects of burn management is FLUID REPLACEMENT Is it important to know what time the burn occurred? YES Why? Fluid therapy (for the first 24 hours) is based on the time the injury OCCURED, not when the treatment was STARTED. Common rule: Calculate what is needed for the first 24 hours and give half of the volume calculated during the first 8 hours. This is the PARKLAND Formula. To calculate fluid replacement properly you also need to know the clients WEIGHT (in kilograms) and TBSA affected. *1 kg = 2.2 pounds If the client is restless it could suggest three problems: inadequate fluid replacement, pain, or hypoxia. *Nurses Priority: HYPOXIA AIRWAY

Which of the following would you choose to determine if a clients fluid volume is adequate? Their weight or their urine output? URINE OUTPUT. Parkland Formula (4ml of LR) X (body weight in kg) X (% of TBSA burned) = total fluid requirement for the first 24 hours after burn 1st 8 hours = of total volume 2nd 8 hours = of total volume 3rd 8 hours = of total volume NCLEX Critical Thinking Exercise: A client weighing 235 lbs. has a 30% total body surface area burns. The physicians prescription is: Titrate IV fluids to maintain urinary output at 0.5 ml/kg/hr. What is the desired output? Record your answer as a whole number. 235 / 2.2 = 106.818181 106.818181 X 0.5 ml/kg/hr = 53. 409 = 53 ml/hr *TESTING STRATEGY* Pain never killed anyone. . Emergency Management: A client was wrapped in a blanket to stop the burning process. Since the flames are gone does that mean the burning process has stopped? NO What else could have been done to stop the burning process? COOL WATER The blanket helped byHolding in the BODY HEAT and kept out GERMS Remove jewelry? Because SWELLING will occur, metal gets hot. Clothing? Remove non-adherent clothing and COVER THE BURNS with a clean dry cloth. Signs of airway injury: SINGED FACIAL/NOSE HAIR, BLISTERED LIPS, ORAL MUCOSA Do you think there is more death with upper or lower body burns? UPPER

A clients respirations are shallow. You know they are retaining what? CO2 Therefore, which acid-base imbalance will they have? RESPIRATORY ACIDOSIS 3. Medication Management: a. Albumin: You know that albumin holds onto FLUID in the VASCULAR SPACE space. Vascular volume? INCREASE VASCULAR VOLUME Kidney perfusion? INCREASE BP? INCREASE Cardiac output? INCREASE Will this help correct a fluid volume deficit? YES Because we are putting more fluid where? FLUID VASCULAR When you start giving a client albumin, you know that the vascular volume will INCREASE. INCREASE WORKLOAD IN THE HEART Therefore, what will happen to the workload of the heart? FLUID VOLUME EXCESS If you stress the heart TOO MUCH: The client could be thrown into fluid volume EXCESS If this occurs, what will happen to Cardiac output? DECREASE Lung sounds? WET In a client who is receiving fluids rapidly, what is a measurement you could take hourly (hint: heart) to ensure youre not overloading the client? CVP CENTRAL VENOUS PRESSURE b. Pain Management: A client has an order for morphine that states: Morphine 2mg IVP or Morphine 4mg IVP Q 2 hours PRN pain. If the client is complaining of pain (4/10) what dosage would the nurse give to the client? 2MG MORPHINE IVP FIRST

Give the LESS amount of narcotics necessary to relieve someones pain. Why are IV pain meds preferred over IM with burns? ACT QUICKLY ASSESS RESPIRATION FIRST _______________________________ ___________ c. Immunization: 1) Tetanus Toxoid: ( TETANUS IMMUNE GOBLIN immunity) *takes 2-4 weeks to develop their own immunity 2) Immune globulin: think IMMEDIATE protection ( PASSIVE immunity) E. Complications: 1. Circulatory System: A client has a circumferential burn on their arm. What does this mean? ALL THE WAY AROUND THE ARM What should you be checking? CIRCULATION If a clients vascular check in their arm is bad what is the name of the procedure to relieve pressure? Escharotomy- relieves the PRESSURE and restores the CIRCULATION , cut through the eschar. Fasciotomy- relieves the PRESSURE and restores the CIRCULATION, but the cut is much deeper into the tissue, cut goes through the eschar and the fascia. 2. Renal System: A foley catheter was inserted so you could measure urine output. How often will this need to be monitored? EVERY HOUR Is it possible that when you insert the catheter that no urine will return? YES Why? Kidneys are either attempting to CONSERVE the fluid or they are not being PERFUSION adequately.

What would you do if the urine is brown or red? Call the PHYSICIAN What drug might be ordered to flush out the kidneys? MANNITOL - DIURETIC If there is no urine output or if it is less than 30mL/hour, you would start worrying about? KIDNEY FAILURE After 48 hours, the client will begin to diurese. Why? Because fluid is going back into the VASCULAR space. Now we have to worry about fluid volume EXCESS So what will happen to urine output now? INCREASE Circulatory check: 1. 2. 3. 4. Hurst Review Services 27 3. Electrolyte Imbalance: The clients serum K+ level is 5.8 Where do we find most of our K+? INSIDE the cell With a burn, what happens to cells? RUPTURE So, what happens to the number of K+ in the serum (vascular space)? INCREASE Electrolyte imbalance? HYPERKALEMIA 4. GI System: Why do you think Carbonate/Magnesium Carbonate (Mylanta), Pantoprazole (Protonix), or Famotidine (Pepcid) are ordered? To prevent a STRESS ULCER, CURLINGS ULCER Why do you think the doctor wants the client to be NPO and have an NG tube hooked to suction? Because they could develop a PARALYTIC ILEUS 1. DECREASED VASCULAR VOLUME. 2. PART OF NORMAL STRESS RESPONSE. 3. HYPERKALEMIA

If a client doesnt have bowel sounds, what will happen to the abdominal girth? INCREASE Do you think the client will need more or less calories? MORE CALORIES, HYPERMETABOLIC STATE, PROTEIN, VITAMIN C The NG tube will be removed when you hear what? BOWEL SOUNDS When you start GI feedings, what should you measure to ensure that the supplement was moving through the GI tract? RESIDUALS What is some lab work you could check to ensure proper nutrition and a positive nitrogen balance? PRE-ALBUMIN, total protein, or albumin. SENSITIVE- PRE-ALBUMIN Antacids: Aluminum Hydroxide Gel (Amphogel), Magnesium Hydroxide (Milk of Magnesium) H2 Antagonist: Ranitidine (Zantac), Famotidine (Pepcid), Nizatidine (Axid) Proton Pump Inhibitors: Pantoprazole (Protonix), Esomeprazole (Nexium) 5. Integumentary System: a. Contractures: Since the client has partial thickness and full-thickness burns, is it possible that they could have problems with contractures? YES If they have burns on their hands, what are some specific measures that may be taken? Wrap each EACH FINGER separately. Use SPLINTS to prevent contractures. Neck Position? HYPER-EXTEND b. Infections: With a perineal burn, the #1 complication is INFECTION. What is eschar? DEAD TISSUE Does it have to be removed? YES

If its not removed can new tissue regenerate? NO What likes to grow in eschar? BACTERIA Classification of Burns: Superficial thickness: formally called first degree burn; damage only to epidermis Partial thickness: formally called second degree burn; damage to entire epidermis and varying depths of the dermis. Full-thickness: formally called third degree burn; damage to entire dermis and sometimes fat c. Tx: What type of isolation will you use with the burn client? PROTECTIVE ISOLATION Sutilanis (Travase) or Collagenase (Santyl): enzymatic drug eats dead tissue Dont use on face CAUSE SCARRING Dont use if pregnant Dont use over large nerves Dont use if area is opened to a body cavity Hydrotherapy is also used to DEBRIMENT a Why should these drugs be alternated? Bacteria will build or . Broad spectrum antibiotics are avoided to prevent SUPER INFECTION Broad spectrum antibiotics may be used until the wound cultures have returned. When giving-mycin drugs.we WORRY when the clients BUN or creatinine increases or if the client complains of any hearing loss. Mycin drugs can lead to ototoxicity (irreversible hearing loss) and/or nephrotoxicity. Check their BUN and creatinine; if they are increasing, assume they are nephrotoxic.

Common drugs used with burns: a. Silver Sulfadiazine (Silvadene)- soothing, apply directly, if rubs off apply more, can lower the WBC, can cause a rash b. Mafenide Acetate (Sulfamylon)- can cause acid base problems, stings, if it rubs off apply more c. Silver nitrate-keep these dressings wet; can cause electrolytes problems d. Povidone-Iodine (Betadine)stings, stains, allergies, acid-base problems 30 Hurst Review Services d. Grafting: Remove the burned dead tissue until healthy tissue is seen. Good skin is taken from healthy donor site and placed over burned area. Now donor site is an open wound, so a transparent dressing is applied until bleeding stops. Then the donor site can be left open to air. If client is well nourished, they can reharvest from same donor site every 1214 days. If the skin graft should become blue or cool what would this mean? Sometimes the doctor will order for you to roll sterile Q-tips over the graft with steady, gentle pressure from the center of the graft out to the edges. Why? e. Chemical and Electrical burns: 1) Chemical burn? First remove client from chemical and begin FLUSH WITH WATER. How long do you flush? 1520MINS 2) Electrical burn 2 wounds. What are they? ENTRANCE and EXIT WOUND What is the first thing you do for an electrical injury?

CONTINOUS HEART MONITOR FOR FIRST 24 HOURS. What arrhythmia is this client at high risk for? V-FIB With electrical burns myoglobin and hemoglobin can build up and cause KIDNEY damage. The client may be placed on a spine board with a c-collar. Why? Electrical injuries occur in HIGH places, muscle contractions can cause fractures, and the force of the electricity can actually throw the victim forcefully. Are amputations common? YES Why? THE CIRCULATORY SYSTEM IS DESTROYED Other complications of electrical wounds: cataracts, gait problems, and just about any type of neurological deficit.