1. Who is at the greatest risk for burns (2)

2. Where do they most often occur?

3. Four goals r/t burns

1. Young kids and elderly at greatest risk.

2. #1 home (kitch and bathroom), work related

3. PREVENTION, lifesaving measures for critically burned, prevention of disability thru early individualized Rx, Rehab

Integumentary Sys Fxn overview

1.Comprised of what?

2. role (2)

3. largest ____ of the body

4. Regulates three things

Integumentary Sys

1. skin, hair, nails

2. shields organs from external envir and barrier to microorganisms

3. Largest organ of the body

4. regulates temp, fluid and electrolyte balance

1. What are the 3 layers of the skin?

2. Epidermis/outer layer: list 4 roles

3. Does the epidermis have bld supply?

1. Epidermis, Dermis, subcutaneous/adipose

2. barrier, synthesis of Vit D (d/t UV rays), receives nutrients via diffusion from the highly vascular dermis layer, regulates temp

3. epidermis does not have a bld supply

Dermis (layer under Epidermis):

1. consists of what

2. Collagen and elastic fibers  =

3. network of capillaries and lymph =

4. Rich what?

Dermis

1. connective tissue

2. flexiblity and mechanical strength

3. oxygen and heat exchange

4. touch, pressure, temp, pain and itch

1. Subcutaneous/adipose layer of skin: 3 roles

2. Define burns

3. what are burns influenced by

4. How should burns be viewed?

1. thermal insulator, shock absorb, protect against mech injury by padding internal organs

2. injury to the tissues of the body d/t heat, chemical, electrical current or radiation

3. temp of the agent, duration of contact, type of tissue

4. PREVENTABLE

1. List the 5 types of burns

2. What is the most common type of burn and what can it be caused by (5 things)?

3. Chemical burns d/t tissue injury and destruction form what?

1. thermal burns, COLD thermal burns, chemical, smoke inhalation, electric

2. Thermal: flame, flash, scald or contact w/ a hot object

3. acids, alkalis, and organic compounds

1. Chemical burns: two things to do

2. Tissue distruction may continue up to ___hrs after a chemical burn

3. Smoke inhalation injuries result from____ and can damage____

1. remove chemical, remove clothing w/ chemical on it

2. 72 hr

3. hot air or chemicals, respir tract

1. smoke Inhalation injuries are results from inhalation of what?

2. Caues damage to what?

3. What is a major predictor of mortality in burn victims?

4. 3 types of inhalation injuries

1. inhalation of hot air or chemicals

2. respiratory tract

3. smoke inhalation = treat QUICKLY

4. CO poisoning, injury above the glottis or below

Smoke inhalation injury d/t CO poisoning:

1. How is CO produced?

2. What does it do to the body?

3. How is it treated?

4. Describe the CO poisoned pt

1. by the incomplete combustion of burning material.

2. displaces oxygen, binds to hemoglobin sites in body, so reduces hemoglobin for body's use

3. 100% humidified O2

4. skin "cherry red," n/v, confused, lethargy

Smoke inhale injury: injury ABOVE glottis:

1. thermally produced =

2. mucosal burns of ____ and _____

3. How can it quickly turn into a medical emergency?

ABOVE glottis:

1. hot air, steam, or smoke

2. oropharynx or larynx

3. mechanical obstruction d/t edema

Injury ABOVE glottis (...cont)

1.  Describe appearance of pt

2. How could throat/airway appear? And what should you do ASAP

1. facial burns, singed nasal hair, hoarseness or painful swallowing, darkeneded oral and nasal membranes, Hx of being burned in enclosed space, clothing burns around chest and neck

2. blisgter and red airway - intubate early before edema to avoid trach

Injury BELOW glottis:

1. injury to r/t

2. Pulmonary edma (aka ____) may not appear until __hrs after the burn

1. r/t the length of exposure to smoke/fumes.

2. ARDS may not appear until 12 to 24 hrs post burn

Electrical Burns:

1. result from ___ caused by _____

2. Also may result from direct damage to __

3. Severity of injury depends 5 things

1. coagulation necrosis caused by intense heat generated from an electric current

2. nerves and vessles

3. amnt of voltage, tissue resisteance, current pathways, surface area, duration of the flow

electric burns

1. Current that passes through ___will produce more life threatening s/s

2. electric sparks may ignite pt clothing causing___

3. What is the "iceberg effect"

1. vital organs

2. combo thermal and elect injury

3. hard to assess severity of injury w/ electr burns d/t most damange below skin

1. Pt w/ electric burns at risk for 3 things

2. treatment of burns is determined by the severity of injury/classification which is determined by 4 things

3. Older terms for burn degree: describe 1st degree, 2nd degree and 3rd degree

1) dysrhythmias, severe metabolic acidosis, and myoglobinuria (kidney)

2) depth, extent of total body surface area, location, pt risk factors

3) 1. 1st: pink/red, healing in 3-5 days, suburn

2nd: red, edema, blister, pain; heal 2 - 6 wk, scald, flames

3rd: red/white/yellow;blk, edema, NO PAIN; graft needed, scalds, flames, grease, chemical

Burn Depth: new way of categorizing burns

1) what are the depth categories?

2. 5 factors to consider whe ndetermining depth

3. Superficial partial thickness burn affects__

4. Deep partial thickness burn affects___

1. partial thickness, full thickness

2. how injury occurred, causative agent, temp of agent, duration of contact, thickness of skin

3. epidermis

4. Dermis

1. Full thikcness burns affect what

2. Superficial partial thickness (epidermis) describe burn

3. deep partial thickenss (epidermis & upper dermis) describe

4. Full thickness (epidermis & all Dermis) describe

1. fat, muscle and bone

2. pain, red, blanch on pressure, dry, may blister, rarely scar, no edema

3. Severe pain, red, fluid exudate, edema, may scar

4. local nerve endings destroyed, white/red/brwn, blk, no pain

1. 3 ways to determine body surface area

2. Rule of 9s, describe

3. Lund and Broser Method describe

1. rule of nines, lund and browder method, palm method

2. each side of head 4.5%, genitals 1%, each side of one arm 4.5%, torso 18%, each side of one leg 9% (both sides of one leg = 18%)

3. more accurate, often used w/kids. Body is divided into sm areas taking into consideration total body surface area (TBSA)

1) What does the Lund-Broder Chart differ from 9s

2) location of a burn is r/t the severity of injury, examples:

face/neck/chest -->

hands, feet, joints, eyes -->

ears/nose, buttock, perineum -->

circumferential burns of an extremity -->

1) TBSA % varies by pt age (ex age 1 head is 8.5% Vs adult is 3.5%)

2. face/neck/chest --> respir

hands, feet, joints, eyes --> self care

ears/nose, buttock, perineum --> infection

circumferential burns can cause circulatory issues

body responses to burns

1) Cardiovascular 5 things

2) Burn edema describe

3) fluid/electrolyte/bld volume 4 things

1. hypovolemia, < perfusion, < oxy delivery, < cardiac output, hypotension

2. systemic edema, peak in 24 hr, resolves 7-10 day

3. hypovolemia, hypoNa, 1st hyperK --> hypo w/ < edema, anemia, false > Hct d/t dehydr

1. Body's pulmonary response to burns (4)

2. 8 Indications of possible pulmonary damage:

1. upper airway injury, INHALATION INJURY, bronchoconstriction, hypoxia

2. burn in closed area, burns of face/neck,

hoarse/voice change, dry cough

stridor, bld sputum, labored breathing,

Erythemia or blistering of the oral/nasal mucosa

1. 4 Phases of burn mgmt: prehospital care,

emergent = aka _____, acute = ______

rehabiliative =______

2. Prehospital care - ON THE SCENE: electrical injuries

3. Prehospital care: chemical

1. emergent = resucitative, acute = wound healing, rehab = restorative

2. Do not touch the victim if still in contact w/ source. Turn off current

3. flush area w/ H2O, flush eyes continously

Prehospital care:

1. Small thermal burns -1

2. Large thermal burns - 4

3. inhalation injury - 2

Prehospital care:

1. small: cover w/ a clean, cool, tap water dampened towel

2. Large: ABCs!! Do not immerse in cool H2O or pak w/ ice, remove clothing, wrap in clean, dry sheet or blanket 

2. inhalant: observe for s/e of respir distress, treat quickly

EMERGENT PHASE / resuscitative

1. last for

2. primary concerns

3. phase begins w/ and ends w/

EMERGENT

1. up to 72 hr

2. concerns are onset of hypovolemic shock and edema

3. begins w/ fluid loss and edema formation and continues until the fluid mobilizes and diuresis begins

Emergent Phase

1. Fluid and electrolyte shifts: high risk for hypovolemic shock

a) caused by

b) can begin when

c) what is depleted?

d) inital vasoconstriction --> ____ = > capilary permeabilty ....this is know as what?

1.

a) massive shift of fluids out of bld vessels as a result of > capillary permeabilty

b) as early as 20 min post burn

c) intravascular volume depleted

d) vasoconstrict from injury --> vessels dialte as immune sys rxn = > cap permeability ===3RD SPACING

1. Third spacing leads to edema but also a risk for

2. Fluid shift is most prevalent when

3. Inital fluid volume shift leads to 5

1. compartment syndrome --> escarotomy may be done

2. 1st 12 hr

3. Hypovolemia, HypoNa, HyperK, Incr H&H, metabolic acidosis

Fluid remobilization - Emerg Phase

1. __hr post trauma

2. what leak stops?

3. fluid shifts back to ____

4. Diuresis and decreased edema

5. What needs to be monitored?

Fluid remobilization

1. 24 - 36 hr

2. plasma to intersitital fluid leak stops

3. fluid shifts back to intervascular space

4. Diuresis and decreased edema

5. H&H and electrolytes

Fluid replacement: MANY different formulas exist:

a) purpose is to

b) calculated based on what

c) formulas are calculated from what

d) fluids given may incld what

a) prevent SHOCK

b) calc based on exten of injury using TBSA of the burn and the weight

c) time of injury

d)bld products, NS, LR

Emerg Phase: Fluid replacement

1. usually calculated fluid volume is given when?

2. Using Parkland formula:

70 kg pt w/ 50% TBSA burn

4 ml/kg/%TBSA

1. 1/2 given in 1st 8 hrs, rest over next 16 hr

2. 4x7050 = 14000 ml/24 hr

1st 8 hr = 700 ml or 437.5 ml/hr

Conditions leading to Burn Shock / Emerg Phase

Burn --> increased cap permeability -->

1. Fluid components of bld leak into interstit = edema, which leads to ________

2. Increase in Hemocrit and bld becomes more___

3. what two components lead to > peripheral resistance?

4. Burn shock is a type of what

1. leads to < bld volume

2. > bld viscosity

3. > bld viscosity and < bld volume

4. Type of hypovolemic shock

Effects of Burn Shock in Emerg Phase

1. During burn shock, in addition to edema, what is the effect on cellular integrity?

2. As the cellular intergrity returns (post shock), what happens?

1. Na moving into cell, K and albumin moves out

2. Albumin remains in the interstitium.   Water and Na remain in circulating volume through the capillaries, K goes into cells, Na transported out of cell back into interstit 

Emerg Phase

1. Describe inflamm and healing....what accumulate at site, what starts wound repair?

2. Immunologic changes

1. neutrophils and monocytes accum at site of injury

fibroblasts and collagen fibrils gegan repair w/in 1st 6 to 12 hrs

2. burn injury causes widespread impairment of immune sys, skin barrier is destroyed

Emerg Phase

1. Airway

2. Breathing

3. Circulation

4. What is HR and BP in hypovolemia

1. 100% O2, provide respir supported as needed, s/s of inhalation injury

2. respir rate and effort

3. pulse, cap refill HR, BP

4. HR >, BP <

Emerg Phase: Nursing collab and Mgmt

1. Hx of how injury occurred

2. PMH and current Rx and allergies

3. asess

4. IV

5. Foley

6. baseline what

7. EKG  8. family suppport

1. time, place, source, treatment, Hx of fall

2. Past Medical HX-- incld TENTUS shot

3. TBSA and depth

4. Large gauge IV 5. Foley

6. height, weight, labs

7.

Emerg Phase: Nursing collab and Mgmt (...cont)

1. Would care

2. Cleaning

3. Debridement

1. should be delayed until pt airway, circ, and fluid replacement has been established

2. can be done w/ cart shower, or bed

3. may need to be done in OR

After emerg phase, may transfer to burn center.

Burns that should be referred to a center incld.

1. partial thickenss burns of

2. Burns that involve what areas

3. 3rd degree burns

4. Electrical and ____

5. Inhalation injury

6. preexisting med disorders that 

1. of greater than 10% of TBS

2. face, hands, feet, genitals, perineum, major joints

3. ALL third degree burns of ALL ages

4. chemical (elect incld lightening)

5.

6. that could complicate mgmt, prolong recovery or effect mortality

Burn criteria (..cont)

1. any pt w/ burns and concomitant trauma like ___in which the burn injry poses the greates risk of morbidity or mortality.  Dr judgment r/t what?

2. Burned children when

3. pt who will require special

1. Dr judgment r/t to stabilize pt before transfer to center..often based on triage protocols

2. hospital w/o qualified personnel or equip for the care of children

3. social, emotional or rehab interventions

1. Burns: first thing is AIRWAY, 2nd is___, 3rd _____

4th_____

2. Monitoring of hydration status in Emerg stage

3. Acute/intermediate phase begins when and ends

1. IV, foley, hydrate

2. I&O, lung sounds, electrolytes, telemetry, invasive monitoring

3. overlaps w/ emerg....begins after given fluids...begins 48 - 72 hrs after injury and lasts until burn closure is complete

1. Acute Phase focuses on what 5 things

2. Acute phase: What returns? What goes away?

Healing begins w/ what?

what sloughs off

what forms?

1. Monitoring respir and circ, electro/fluid balance, infection (sepsis #1 cause of death), wound care, pain mgmt

2. Bowel sounds return, less edema,

WBCs surround the burn and phagocyc occurs

necrotic tissue sloughs

Granulation forms

Acute phase

1. Partial thickness burn heals how?

2. Full thickness burn heals how?

3. cardiopulmonary: monitor for what?

1. partial: from the edges. They form eschar. Once eschar is removed, re-epithelia begins 

2. full: must be covered w/ a graft After REQUIRED debridement

3. CHF, pulm edema, airway obstruction

Acute Phase

1. Monitor for sepsis

2. neurologic sys

3. Musculoskeletal

4. GI

5. Endocrine sys

1. fever

2. Disoriented? combative?

3. ROM, contractures

4. paralytic ileus - PPI given

5. incr bld glucose, incr insulin produc, hypergylcemia

Acute stage: prevent infection

1. Burn eschar describe

2. primary source of bacterial infection is what?

3. __becomes permeable

4. do routine what

5. what type of antibiotics

1. no bld supply, so antibodies cannot reach it, lrg # of bacteria appear and can spread into circ

2. intestianl tract

3. mucosal barrier

4. wound culture

5. topical NOT systemic (cuz no bld supply to it)

acute phase: collaborative mgmt

1. Wound care

Excision and grafting

pain mgmt

PT and OT, nutritional

Pschyosocial

1. daily observe, assess, cleanse, debride, dressings

wound care:

1. Enzymatic debridement

2. wounds are cleaned w/

3. then covered w/ what

4. Hydrotherapy

5. ___technique

6. topical antibiotic Rx list 4

1. speeds up removal of dead tissue

2. soap and water or NS moistened gauze

3. topical antimicrobial cream

4. for debride

5. aseptic technique

6. Silvadine, Sulfamylon, silver nitrate, Acticoat

1. Dressings

2. Grafting

permits ___, reduces ____

autograft

biologic dressings: two

synthetic

dermal substitiues

1. preRx, wide variety of choices of dressings, protective gear

2. permits ealier fxn ability, < contractures

autograph - own skin

biologic: homograft (human), hemograft (animal/pig)

1. What is a Cultured epithelial autographs

2. Pain Rx

3. PT and OT goal

4. why is it a good time to exercise during wound cleaning?

1. CEA: grown from biopsies from pt own skin.  Used in pt w/ lrg body surface area or those w/ limited skin to harvest

2. Opiods (morphine or fentanyl), IV most effective, PCA pump, nonpharmacologic options

3. maintain muscle strength and optimal joint fxn

4. pt medicated

1. pt in a hyper metabolic stage, so nutrition -

2. When does Rehabilitation phase begin

3. Burn wounds heal how

4. layers of epithelialization begin to rebuild structure, collagen adds

1. high protein, high calorie, Enteral feedings start asap

2. when burn is healing, pt is able to resume a level of self care

3. by either primary intention or grafting

4. strength to weakened areas

1. New skin appears

2. In 4 - 6 weeks, new skin appears

3. Mature skin is reached when (time)

1. new skin appears flat and pink

2. 4 - 6 wks appears raised and hyperemic. skin never regains orig color

3. Mature healing is reached in 6 mo to 2 yr

Rehab Phase...cont

1. pressure can help w/ what?

2. newly healed area can be hypo or hypersensitive to

3. Must be protected from sun for how long

1. keep scar flat

2. cold, heat, touch

3. 1 yr out of sun

1. Skin and joint contractures most common prob in REHAB phase.  How to help avoid this.

2. collaborative mgmt in rehab phase

3. NDX 4

1. position, splint, exercise

2. teach family how to care for wound, emolient water based cream, cosmetic surg, role of exercise, reassure n encourage

4. risk for altered body temp, self care deficit, ineffect coping, knowledge deficit, social isol

Prevention

1. Home water temp notes

2. During the emerg phast, the pt should be assessed for what electrolyte bld values? 2

3. Drug of choice for pain relief following a burn injury

1. bath water 100 or <, hot water heater 120 or less, face child away from faucet

2. Na deficit, K excess

3. Morphine #1, fentanyl