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Nursing care of a burn Client
Burns
57
Nursing
Undergraduate 2
02/08/2011
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Term
first thing you do when arriving at the scene?
 Definition
 #1 priority – scene assessment, is the scene safe?
Term
How long do you cool the burn?
 Definition
 Cool burns for 5” only
Term
What are appropriate dressings to cover the burn with?
 Definition
 Cover the burn area with a clean dry dressing. (Baby diaper,Pillow case, towel) covering lowers pain and covers nerve endings. DON’T PUT ANY OINTMENTS OR PETROLEUM ON BURN!!! AFFECTS THE GRAFTING.
Term
After cooling the burn, what is your next priority?
 Definition
 Maintain a warm environment
Term
 What does Capillary and cell wall destruction lead to?
 Definition
this leads to vasoconstriction, thrombosis, ischemia
Term
 With Increased capillary permeability there is?
 Definition
is a seepage of plasma proteins, fluids and electrolytes shift into the interstitial tissues which in turn causes blister formation and edema.
Term
Cardiovascular changes with 20-50% burn?
 Definition
decreased circulating volume, which initially causes a decrease in cardiac output.
Term
Respiratory changes with 20-50% burn?
 Definition
tissue damage and localized edema with less air movement due to the shift of fluids on the lungs (~2L)
Term
• GI – hypo-perfusion with 20-50 % burn?
 Definition
. State of diuresis after 48-72 hours • Renal- there will be a decreased output initially due to decreased perfusion. State of diereses after 48-72 hours
Term
• Immune suppression with 20-50 % burn?
 Definition
– first line of defense had been destroyed when skin is burned.
Term
• Hyper metabolism with 20-50 % burn?
 Definition
the body’s response to a burn has been classified as hyper dynamic, hyper metabolic and hyper catabolic. Hyper Metabolic -burning extra calories to survive. NEED 7000 CALORIES TO SURVIVE!
Term
Hospital priority for a burn victim?
 Definition
the burn victim is a trauma client, stabilize then treat the burn
Term
Airway
 Definition
may need to be intubated, this will be done before there is problems.
• Airway will occlude with edema
Term
 Breathing
 Definition
significant predictor of mortality.
• s/s of injury is not always present initially.
• O2 100% per non-rebreather mask
Term
• 3 types of respiratory injury
 Definition
o Carbon monoxide
o Upper airway – thermal
o Lower airway – smoke or chemical
Term
 Circulation
 Definition
• Control hemorrhage/stop bleeding
• Initiate fluid resuscitation
• Awareness of circumferential burns
• Monitor B/P and Pulse
• Cardiac monitor
• CPR
Term
 Fluid resuscitation
 Definition
– start 2 large bore IV’s
Term
 Site of IV?
 Definition
• Peripheral unburned
• Peripheral burned
• Central line – femoral
• Cut-downs only if necessary
Term
 Amount of fluid until % of burn calculated
 Definition
• < 5 years = 150 mL/hr
• 5-15 years = 250 mL/hr
• >15 years = 500 mL/hr
Term
What are the 3 D's?
 Definition
 Disability, Deformity, Neuro Deficit
Term
 Baseline Neuro status =
 Definition
LOC
Term
What are the causes of Altered LOC?
 Definition
related to hypoxia, carbon monoxide, head injury, drug or alcohol use.
Term
 Glasco Coma Scale
 Definition
• A=alert
• V=responds to verbal
• P=responds to pain
• U=unresponsive
• Pupillary response
Term
What to assess on burns?
 Definition
• Depth of burn
• % of burn are involved
Term
1st degree burn?
 Definition
superficial burn, redness, painful, blanches. Epidermis only is involved, heals in 3-5 days. 1st degree burns are not included in % TBSA
Term
 2nd degree
 Definition
partial thickness burn, blisters, moist, blanches, painful. Epidermis and part of dermis involved, heals in 7-12 days.
Term
Third Degree:
 Definition
full thickness burn, dry, discolored, leathery, no pain, non-elastic. Epidermis, dermis and subQ layers involved. Surgical intervention is needed.
Term
Fourth Degree:
 Definition
– full thickness burn, charred, leathery, dry, no pain. Muscle and bone will be involved. Surgical intervention needed.
Term
% of burn – assessing the amount of area involved
 Definition
o Rule of nine
o Lund and browder chart
o Open hand fingers together of client
Term
What percent are the legs?
 Definition
18 %
Term
What percent are the arms?
 Definition
9%
Term
What percent of the front?
 Definition
18%
Term
What percent is the back?
 Definition
18 %
Term
What percent is the whole head?
 Definition
9 %
Term
What percent is the groin?
 Definition
1 %
Term
What percent is the face
 Definition
4.5 percent
Term
What percent on a child is the legs?
 Definition
14 %
Term
What percent on a child is th arms?
 Definition
9 %
Term
What percent on a child is the front?
 Definition
18
Term
What percent on a child is the back?
 Definition
18
Term
What percent is the childs whole head?
 Definition
18
Term
Lab and diagnostic considerations
 Definition
 ABG’s especially look at carboxyhemaglobin
 CBC
 Lytes
 Glucose
 BUN/CREATININE
 Drug and alcohol screen
 Type and cross
 CXR
 X-ray associated trauma/abuse
 EKG*
Term
Interventions for pain
 Definition
o Cover partial thickness burns
o IV pain medication only, MS 2-5 mg as needed also use of Versed to sedate.
o Avoid overmedicating, mask s/s and limit participation in the decision making
o Monitor respiratory depression
Term
Nursing Care
 Definition
VS
• Initially VS will give you a picture of the client’s level shock and complications of the fluid shift/loss
• Later VS will identify s/s of infection, which is the #1 cause of death with burns.
I/O and daily weights – best measurements for fluid balance

VS
• Initially VS will give you a picture of the client’s level shock and complications of the fluid shift/loss
• Later VS will identify s/s of infection, which is the #1 cause of death with burns.
I/O and daily weights – best measurements for fluid balance
• Initially VS will give you a picture of the client’s level shock and complications of the fluid shift/loss
• Later VS will identify s/s of infection, which is the #1 cause of death with burns.
I/O and daily weights – best measurements for fluid balance
Term
Respiratory status -
 Definition
• Ongoing with the use narcotics
• With inhalation burns monitor respiratory status related to edema.
• Cinged nasal hairs, sooty sputum are sighs of respiratory involvement
Term
Wound care:
 Definition
• If transfer will occur within 1st 24hrs, no debridement and no topical applications. Cover burns, saran wrap effective cover.
• If transfer after 24hrs; debride the large blisters (>2 cm) and clean with diluted microbial soap. Apply recommended ungt and wrap with gauze.
• Always wrap fingers and toes separately.
• Ointments used to the wounds include; sivadene, sulfamylon, silver nitrate, acticoat
Term
Debridement –
 Definition
• Purpose to remove eschar, promote healing, prevent infection, prepare wound for definitive coverage/healing.
• Expect to see copious amounts of wound drainage, serous-yellow.
• A part of debridement is removal of hair shave 1-2” margin of the unburned skin. Hair traps debris and old topicals and favors bacterial growth.
• Need for the removal of all previous agent applied to the burns.
Term
Assessment of GI function
 Definition
• Need for gastric decompression until BS return, from the paralytic ileus.
• Because of the tremendous stress of the burn, clients are at risk for curlings ulcer or stress ulcer.
• Appetitie is affected by the amount of pain, smells and the on going stress of burn care.
Term
Nutrition
 Definition
• Metabolic rates are 20-75% above normal with >40% burn area metabolic rates have demonstrated to be 200% above normal
• Caloric intake needs = 5000kcal or greater per day.
Term
Autograft
 Definition
skin harvested from uninjuried client skin
Term
Allograft/homograft
 Definition
skin harvested from another human being
Term
Heterograft/zenogaft
 Definition
skin harvested from other animal species (pig skin
Term
Split-thickness graft
 Definition
removing the epidermis from the client (allograft) the graft is slit (meshed) and can cover a larger area of burn.
Term
Split-thickness graft
 Definition
removing the epidermis from the client (allograft) the graft is slit (meshed) and can cover a larger area of burn.
Term
Full thickness graft
 Definition
removing all the layers of skin and transfer to the involved area
Term
Postage stamp graft
 Definition
like the split-thickness graft but smaller.
Term
Partial thickness burns require what kind of dressing?
 Definition
require biological dressing to help with fluid loss, decrease pain, and for moisture to the skin surface. Utilize;
 Zenografts
 Dermal regenerative grafts such as Biobane or BCG Matrix
 Silver impregnated dressing
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