Exam 3 Blueprint On Burns, ICP, SCI PDF

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Studyguide for 3rd exam on burns, ICP, SCI...

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TISSUE INTEGRITY-BURNS (20) ●

Fluid Replacement ○ Calculations ■ Consensus Formula ■ 2-4 mL x kg body weight x BSA burned ■ Half of total fluids given in first 8 hrs ■ (EX) If pt gets burned at 0200 and you don’t get that pt until 0400, then you start the 8 hrs at 0200! So we give the calculated fluid amount over 6 hrs b/c 2 hrs already went by of the 8 hrs! ■ Other half in next 16 hrs ■ Use isotonic solutions → 0.9%, LR ■ LR is the 1st choice in treating people with fluid volume deficit b/c it is most similar to our bodies extracellular fluid contents! ■ Avoid colloids during first 24 hrs → colloids will cause more fluid buildup b/c they do not help with fluid shifting ■ Monitor urine output for effectiveness → 30-50 ml/hr!!! ■ 75-100 ml/hr for electrical ■ Monitor mental status and urine specific gravity ■ PARKLAND FORMULA ■ 4 mL x body weight in kg x TBSA% burned ■ BROOKE → modified → FORMULA ■ 2 mL x body weight in kg x TBSA% ■ The difference between Parkland and Brooke formulas is the VOLUME! ○ Administration ■ The amount of fluid to give is based on weight and extent of injury ■ Fluids are calculated from the time of injury, NOT THE TIME OF ARRIVAL AT THE ER! ■ Goal is to prevent shock! ■ Body weight & percentage of BSA for fluid resuscitation calculation! ■ To maintain a urinary output of 30-50 ml/hr → 0.5 - 1.0 cc/kg/hr ■ Evaluated by stable VS, adequate urine output, palpable pulses, & clear sensorium ○ Complications ■ Fluid overload → listen to lung sounds ■ Most likely will hear crackles ○ Evaluation ■ Stable vitals, adequate UO, palpable pulses, clear sensorium ■ Serum electrolytes are monitored ■ If H&H decrease or if urine output exceeds 50 ml/hr → IV fluid may be decreased

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Want a MAP of 60-65 b/c that tells us that all the organs are being perfused!

Phases ○ Emergent / Resuscitative Phase ■ Begins at the time of injury and ends when fluid mobilization & diuresis occurs → usually within 24-48 hrs ■ Primary goal is to prevent hypovolemia & preserve vital organ function → RELATIVE HYPOVOLEMIA b/c fluid is not lost, just shifted! ■ Pre-hospital ■ Remove from source ■ Assess ABCs ■ Assess for trauma ■ Conserve body heat ■ Cover burns with clean cloth ■ Remove constrictive clothing / jewelry ■ Leaving these on can cause the pt to continue to burn so take everything off! ■ Assess need for IV fluids ■ Transport ■ ER care ■ Calculate degree & extent of burns ■ Ensure patient airway ■ Assess for respiratory distress ■ Assess oropharynx for blisters ■ Need intubation ■ Intubate these pts prophylactically if you know their airway is going to swell ■ 100% O2 ■ IV therapy → 2 large bore ■ Monitor VS & ABGs ■ Insert foley & NG ■ NG is put in b/c pt can get a paralytic ileus d/t decreased inactivity OR from the burn trauma so NG can decompress ■ Foley is placed in case urethra is damaged and to reduce stress on body ■ Pain medications ■ Prepare for escharotomy ■ Escharotomy ■ Lengthwise incision through the burn eschar to relieve pressure & improve circulation ■ At the bedside without anesthesia

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Nursing Care: ■ Assess pulses ■ CMS of extremity ■ C → color ■ M → motion ■ S → Sensation ■ Control bleeding with pressure & pack with fine mesh gauze w/ antimicrobial solutions ■ Apply topical antimicrobials ■ THESE WILL NOT WORK ON FULL THICKNESS BURNS! Fasciotomy ■ Incision made extending through the subcutaneous tissue done in the OR ■ Goes through subQ tissue into the fascia aka muscle ■ This is done if adequate perfusion is not restored with an escharotomy ■ Nursing Interventions: ■ Monitor pulses & CMS ■ Control bleeding with pressure ■ Apply topical antimicrobial solutions

■ Tetanus Nursing Diagnoses Emergent phase ■ 1) Ineffective airway clearance ■ 2) Impaired gas exchange ■ 3) Ineffective breathing pattern ■ 4) Fluid volume deficit ■ 5) Altered tissue perfusion ■ 6) Decreased cardiac output ■ 7) Impaired skin integrity ■ 8) Pain ■ 9) Ineffective thermoregulation ■ Priorities → 1) AIRWAY 2) BREATHING 3) CIRCULATION Interventions for Resuscitative Phase ■ Monitor for tracheal and laryngeal edema ■ Monitor ABGs and pulse ox ■ Elevate HOB for facial burns ■ Elevate any extremities that are burned to prevent as much edema as possible!

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If a lot of body parts are burned, then elevate the most important ones

EKG Monitor for infection ■ Perineal area is the biggest risk for infection! Cut body hair around burn ■ Cut hair around perineum b/c can harvest bacteria and cause infection Monitor stools for occult blood Elevate circumferential burns ■ Circumferential burns around the thoracic aka chest area can cause decreased chest expansion Monitor perfusion of the extremities Keep room warm → 85 degrees Keep sheets off burn → ‘CRADLE’ technique Assess for ileus ■ Drain the gut until its able to absorb again Daily weights → gain about 15-20 lbs the first 72 hrs d/t swelling Monitor for stress ulcers & administer anti-ulcer medications ■ Usually ALWAYS on Famotidine or Protonix to prevent Curling’s ulcers and stress ulcers! Protective isolation ■ We wear special, protective isolation gear head-to-toe to protect the pt from us & the environment since their first natural barrier → the skin → is burned!

Begins with diuresis, stable capillary membranes, and stable vital signs Occurs 48-72 hrs after injury Restorative therapy Focus is on infection control, wound care, nutritional support, pain control, and physical therapy They are peeing sustainably at this time! Nursing Diagnosis Acute Phase ■ Risk for infection ■ Fluid volume excess ■ Impaired skin integrity ■ Pain ■ Altered Nutrition → less than body requirements ■ Impaired physical mobility ■ Altered thermoregulation ■ Altered family processes ■ Ineffective coping

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Rehabilitation

Wound Care ○ Hydrotherapy ■ Wounds are cleansed by immersion, showering, or spraying ■ 30 mins or less to prevent increased sodium loss, pain, heat loss, and stress ■ Premedicate!!! ■ Not used if unstable ■ Minimize bleeding and maintain body heat ■ Very useful in wound debridement ○ Debridement ■ Mechanical ■ Use of scissors and forceps to lift and trim away eschar ■ Wet-to-dry dressings ■ Major problems are pain and bleeding ■ Enzymatic ■ Application of proteolytic and fibrinolytic topical enzymes that digest necrotic tissue which facilitates eschar removal ■ Accuzyme ■ Elase ■ Surgical ■ Excision of eschar and coverage of wound ■ Tangential ■ Shaving of thin layers of eschar until viable tissue is reached ■ Fascial ■ Used for deep burns and removal of burn tissue and underlying fat down to the fascia ○ Topical Anti-Infectives ■ Silvadene → MOST COMMONLY SEEN! ■ Sulfamylon ■ Bacitracin ■ Bactroban ■ Nystatin ■ Nickel thickness is how much you put on ○ Wound Closure ■ Prevents infection ■ Promotes healing ■ Prevents contraction ■ Temporary Wound Closure ■ Objective of this approach is to actively alter the quality and rate of healing of a partial thickness burn ■ Permanent Wound Closure

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■ Split-thickness skin grafts ■ Full-thickness skin grafts Temporary Skin Substitutes Versus Topical Antibiotics ■ Clinical Advantage Skin Substitutes ■ Markedly reduces pain ■ Decreased heat, water loss ■ Decreases wound inflammation, drainage ■ Prevents surface drying in superficial wounds ■ Increases rate of epithelialization ■ Decreases surface infection ■ Disadvantages ■ Does not control deep infection ■ Can seal bacteria in as well as out ■ Biologicals can transmit infection ■ Indications ■ Superficial to mid second-degree burn ■ Clean, excised wound ■ Skin donor sites ■ Since adherence is essential for effectiveness, wound bed must be debrided to viable tissue ■ Since temporary skin substitutes have no intrinsic bactericidal properties, the wound surface must not be infected Temporary Wound Coverings ■ Amnion → amniotic membranes from human placenta are used and the dressing is changed q 48 hrs ■ Allograph Homograph → donated human cadaver skin is provided through a skin bank ■ Xenograft Heterograft → porcine skin that is replaced q 2-5 days ■ Porcine = pig skin ■ Biosynthetic & Synthetic ■ Biobrane ■ When biobrane appears opaque, this signifies healing ■ Temporary ■ Vigilon Grafting ■ Autografting ■ Provides permanent wound coverage ■ Surgical removal of a thin layer of unburned skin which is then applied to excised burn wound ■ May use mesh or sheet grafting ■ May also see use of skin grown in culture from patients own cells → CEA ■ Done in the OR

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Rehab ■ ■ ■ ■ ■ ■

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Burn must have a good blood supply, free of infection, & totally debrided before a graft is done ■ Full thickness burns will NEVER regenerate new tissue; therefore, you will have to do an autograft! ■ Full thickness graft → skin is WHOLE ■ Used on hands and face → places that are seen all the time ■ Mesh graft → makes cuts in the skin so you can use less skin on more part of the body ■ Looks like a chain linked fence → used on legs, abdomen, arms Care of Grafts ■ Monitor for bleeding ■ If ordered, blood can be removed from under the graft by gently rolling fluid from the center of the graft to the periphery and absorbed with gauze ■ Large accumulations are removed with a syringe by the MD ■ Graft can fall off if not adhered to the surface tightly d/t gas, air bubbles, or blood therefore those need to be removed for the graft to adhere correctly → need smooth surface ■ Autografts are immobilized after surgery for 3-7 days → position for immobilization and elevation at the site ■ Elevate ■ Keep site from pressure ■ Avoid weight bearing ■ Remove exudate ■ Monitor for hematomas and infection ■ Instruct client to avoid using fabric softener and harsh detergents ■ Instruct client to protect skin from the sun → use coco butter and splints and support garments ■ Splint joint in a position of function NOT comfort Promotes wound healing Minimizing deformities Increase muscle strength Provide emotional support Trying to get them to the most optimal level of functioning! Physical Therapy ■ ROM ■ Ambulate to maintain strength ■ Apply splints to protect joints ■ Dynamic splints exercise the affected joints ■ Avoid pressure Nursing Diagnoses Rehab Phase

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Pain Disturbed body image Ineffective coping Role strain Knowledge deficit Altered family processes Impaired skin integrity

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Pain Management ○ Morphine IVP ○ Avoid IM d/t fluid shifts ○ Avoid oral route d/t ileus ○ MEDICATE BEFORE PAINFUL PROCEDURES AND REHAB ○ Allow pt as much control over pain management as possible ○ PCA pumps are common b/c they give the pt the best pain control

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Hypovolemia ○ Hypovolemic shock greatest initial threat 1st 24hrs b/c cap permeability ○ Cap perm decreases in 18-24hrs and returns to normal in 2-3wks ○ Vasoactive substances released that increase cap perm → fluid shifting ○ Protein loss → colloid oncotic pressure decrease → results in more fluid shifts ○ 3rd spacing occurs w blisters / exudate formation & edema ○ Insensible losses r/t fluid evaporation from wound beds → until wound closed ○ Hemoconcentration & Hct increase ○ Electrolyte’s shift → Na into cells → decrease Na & K out of cells → increase K ○ Relative fluid loss more important ○ Plasma leaves interstitial tissue → sodium & albumin follows so they will both be decreased → edema → hematocrit will be increased until fluid is restored and then it will be decreased → in acute phase → blood will be thick → potassium will be increased d/t injured cells → WBC & immunoglobulins will be decreased → intravascular system has no fluid in it → so you will have an increase HR, decrease CO, and decreased BP → Initially patient will be oliguric d/t all the fluid moving out → Monitor urine for myoglobin & hemoglobin

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Ulcer Prevention ○ GI problems occur d/t decreased perfusion and increase in acid production d/t the stress response ○ Stress ulcer → Curling’s → patient may have pain, N/V, and blood → look at stool for occult blood ○ Patient will be NPO and have an NG tube to remove air & secretions ○ Monitor BG for hyperglycemia d/t stress response → liver will release glycogen ○ Anti-ulcer medications → PPI/H2 blockers

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Type of Burn & Location ○ Staging ■ Burn Severity ■ MINOR → ER/OUT PT ■ Partial thickness 10% ■ Hands, face, eyes, ears, genitalia ■ Concomitant trauma ■ Poor risk pt ■ Types of Burn Injury ■ Thermal ■ ■ Chemical ■ ■ Electrical ■ ■ Radiation ■ ■ Smoke Inhalation ■ ■ Classification of Burns ■ Small burns = the body has a localized response ■ Large burns cover over 25% of the body and all major systems are affected ■ Depth ■ SUPERFICIAL → 1st DEGREE→ EPIDERMIS ■ Sunburn, Low-Intensity Flash, Superficial Scald ■ Clinical Manifestations: ■ Tingling ■ Hyperesthesia → hypersensitivity ■ Pain that is soothed by cooling ■ Peeling ■ Itching ■ Wound Appearance: ■ Minimal or no edema

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■ Possible blisters ■ Mild to severe erythema ■ Skin blanches with pressure ■ Painful ■ Discomfort about 48 hrs with healing about 3-7 days ■ Skin grafts not required ■ Tx → oral pain meds, cold compress, skin lubricants PARTIAL THICKNESS → 2nd DEGREE → EPIDERMIS & PORTION OF DERMIS ■ Scalds, Flash Flame, Contact ■ Clinical Manifestations: ■ Pain ■ Hyperesthesia ■ Sensitive to air currents ■ Wound Appearance: ■ Large blisters ■ Edema ■ Mottled red base and broken epidermis with wet shiny appearance ■ Painful ■ Weeping surface ■ Heals in 2-3 weeks ■ Some scarring and depigmentation possible ■ Deep 2nd degree burn heals in 3-6 weeks with possible grafting FULL THICKNESS → 3rd DEGREE → EPIDERMIS, DERMIS, & SOMETIMES SUBQ - MAY EVEN INVOLVE CONNECTIVE TISSUE & MUSCLE ■ Flame, Prolonged Exposure to Hot Liquids, Electric Current, Chemical, Contact ■ Clinical Manifestations: ■ Insensate ■ Shock ■ Myoglobinuria → red pigment in urine & possible hemolysis → blood cell destruction ■ Possible contact points → entrance or exit wounds in electrical burns ■ Wound Appearance: ■ Leathery or charred ■ Coagulated vessels may be visible ■ Edema ■ Deep red, black, brown, pale white or yellow area

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■ Injured surface appears dry ■ Tissue disruption with fat exposed ■ Little pain ■ Spontaneous healing will not occur ■ Scarring and contractures will occur without preventative measures ■ Eschar may slough ■ Grafting necessary ■ Scarring and loss of contour & function ■ Healing takes weeks to months DEEP FULL THICKNESS → 4th DEGREE → DEEP TISSUE, MUSCLE, FAT, FASCIA, & BONE ■ Prolonged Exposure or High Voltage Electrical Injury ■ Clinical Manifestations: ■ Shock ■ Myoglobinuria ■ Possible hemolysis ■ Injuries to muscle and bone ■ Wound Appearance: ■ Injured area appears black or charred ■ Edema is absent ■ Healing takes weeks to months ■ No pain ■ No blisters ■ Eschar is hard and inelastic ■ Grafts are required

Extent ■ Direct Thermal Injury to Lungs ■ Affects lower airways by inhalation of steam or scalding liquids ■ Injury to upper airways results in edema ■ Injury can result in obstruction during 24-48 hrs ■ Endotracheal intubation may be required ■ Coughing up grayish brown or black mucus is a big sign of direct thermal injury to lungs! ■ Smoke Inhalation Injury ■ Injury results when a victim is trapped in an enclosed, hot, smoke-filled place ■ Assessment ■ Facial burns ■ Erythema

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Complications

Swelling of oro-nasopharynx Singed nasal hair Flaring nostrils Stridor, wheezing, dyspnea, hoarse voice, sooty sputum, agitation, tachycardia → worry about pts airway if you see these things!! ■ Smoke Poisoning ■ Caused by inhalation of the byproducts of combustion ■ A localized inflammatory reaction occurs causing a decrease in bronchial ciliary action and a decrease in surfactant ■ Assessment ■ Mucosal edema ■ WHEEZING ■ Hemorrhagic bronchitis ■ ARDS ■ CO Poisoning ■ Clinical Manifestations per Blood Level % ■ 1-10% → impaired vision ■ 11-20% → flushing, headache ■ 21-30% → nausea, impaired dexterity ■ 31-40% → vomiting, dizziness, syncope ■ 41-50% → tachypnea ■ >50% → coma and death ■ Carbon Monoxide Poisoning Location ■ Burns of head and neck → pulmonary complications ■ Burns of the face → corneal abrasion ■ Burns of the ears → auricular chondritis → inflammation of the cartilage of the ear ■ Burned hands and joints require extensive therapy to prevent disability ■ Perineal area risk for contamination → biggest risk for infection! ■ Circumferential burns of the extremities can cause compartment syndrome ■ Circumferential burns of the thorax aka chest can cause pulmonary insufficiency d/t decreased chest expansion Age ■ Pre-Existing Conditions ■

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Care ■

CARDIOVASCULAR ■ Hypovolemia / shock → r/t fluid shifts ■ Hemoconcentration & RBC destruction ■ Decreased CO ■ Decreased tissue perfusion → r/t circumferential extreme burns ■ Dysrhythmias, cardiac arrest → electrical burns RENAL ■ ARF → from ATN r/t decreased perfusion & renal ischemia ■ F&E imbalances → decreased Na & increased K from fluid shifts ■ Hemoglobinuria, myoglobinuria → seen with full-thickness & extreme electrical burns ■ Metabolic acidosis → from electrical burns RESPIRATORY ■ Airway edema / obstruction → direct thermal burns such as neck, face, chest ■ Direct damage ■ Pulmonary edema → d/t fluid shifts ■ Pulmonary HTN ■ Pneumonia → leading cause of death in pts with inhalation injury! IMMUNE ■ Decreased function → infection b/c bodys 1st line of defense is damaged GI ■ Ileus → from decreased blood flow to GI ■ Stress ulcer → Curling’s ■ Hepatic failure → increase in blood flow MUSCULOSKELETAL ■ Atrophy → from immobility ■ Contractures → from immobility & deep scarring in burns ■ Bone calcium loss INTEGUMENTARY ■ Evaporative loss → contributes to fluid loss ■ Nitrogen loss ■ Eschar → can contribute to respiratory problems b/c it becomes tight ■ Edema Pre-hospital care → done by paramedics ■ Remove pt from source ■ (EX) get them out of burning building ■ Assess ABCs and assess for trauma

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Conserve body heat → cover burn w dry sheet to prevent infection and remove constrictive clothing → don’t remove adherent ■ Assess need for IV fluids ■ Transport ■ ER care → calculate degree & extent of burns ■ Need to know pts weight asap ■ Ensure patent airway → assess for respiratory distress and assess oropharynx for blisters ■ Provide 100% humidified O2 → if inhalation injury ■ If pt is in respiratory distress → intubate & mechanical ventilation ■ IV therapy → 2 large bore catheters → if burn >15% TBSA ■ Monitor vitals, ABGs, LOC, O2 sat, ECG ■ Insert foley & NG tube ■ Pain meds → IV ■ Elevate burned limbs ■ Prepare for escharotomy → removal of dead tissue ■ Lengthwise incision through the burn eschar to relieve pressure & improve circulation ■ Tetanus vaccine → given routinely to all burn pts b/c anaerobic burn wound contamination ■ Interventions ■ Elevate HOB for facial burns → w blanket roll behind neck & elevate circumferential burns ■ Protective isolation PPE → hat, mask, gown, gloves → d/t risk for infection ■ Monitor for infection → cut body hair around burn b/c can cause infection ■ Daily wts → gain about 15-20lbs in 1st 72hrs from swelling & fluids ■ Monitor for stress ulcer → stool for occult blood & bowel sounds ■ PPIs, H2RBs ■ Monitor perfusion of extremities → if decreased pulses or numbness → notify HCP ■ Prevent shivering → keep room warm @ 85 degrees → b/c they lost the ability to regulate temperature if hypodermis is damaged ■ Keep sheets off of burn → cradle technique Positioning ■ Elevate HOB for facial burns → w/ blanket rolled behind neck ■ Avoid pillows → too much pressure on neck/ear burns ■ Have pt stretch & move burned body parts as much as possible → to prevent contractures ■ ...