Timby's Introductory Medical-Surgical Nursing: Chapter 66: Caring for Clients w/ Burns Flashcards


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1

Shifts in fluids and electrolytes w/ burn clients

AFTER A BURN, FLUID FROM THE BODY MOVES TO THE BURNED AREA, WHICH ACCOUNTS FOR EDEMA AT THE BURN SITE

SOME OF THE FLUID IS THEN TRAPPED IN THIS AREA AND RENDERED UNAVAILABLE FOR USE BY TEH BODY, LEADING TO INTRAVASCULAR FLUID DEFICIT

DECREASED BLOOD PRESSURE FOLLOWS

IF PHYSIOLOGIC CHANGES ARE NOT IMMEDIATELY RECONGIZED AND CORRECTED, IRREVERSIBLE SHOCK IS LIKELY

ANEMIA DEVELOPS B/C HEAT LITERALLY DESTROYS ERYTHROCYTES

2

What does a burn assessment include?

  • DETERMINATION OF THE DEPTH OF THE BURN
  • CONSIDERATION OF THE ZONES OF THE BURN INJURY
  • AN ESTIMATION OF THE EXTENT OF THE BURN INJURY BASED ON THE PERCENTAGE OF THE TOTAL BODY SURFACE AREA THAT HAS BEEN BURNED

3

This client presents w/:

  • sore throat
  • singed nasal hairs, eyebrows, eyelashes
  • hoarseness
  • carbon in sputum
  • soot around the mouth or nose
  • SOB
  • stridor

SIGNS OF HEAT OR SMOKE INHALATION INJURY

4

This burn is similar to a sunburn

  • epidermis is injured, dermis is UNAFFECTED
  • burn is red and painful
  • heals in less than 5 days
  • infection, increased metabolisms and scarring doesn't occur

SUPERFICIAL BURN

5

This burn:

  • affects the epidermis and dermis
  • hair follicles remain intact
  • client has mottled pink to red, painful, blistered or exuding fluid, blanches w/ pressure

SUPERFICIAL PARTIAL THICKNESS BURN

6

This burn:

  • affects the deeper layer of the dermis w/ damage to sweat and sebaceous glands
  • client has a variable color from patchy red to white, wet or waxy dry, doesn't blanch w/ pressure, sensitive to pressure only

Deep partial thickness

7

This burn:

  • affects the epidermis, dermis, and subcutaneous tissue (fat, fascia, muscle, bone)
  • destroys all layers of the skin
  • experiences NO pain
  • tissue appears lifeless
  • IF NOT DEBRIDED, THIS BURN CAN LEAD TO SEPSIS, EXTENSIVE SCARRING, AND CONTRACTURES
  • WILL NEED A SKIN GRAFT

FULL-THICKNESS BURN (3RD AND 4TH DEGREE BURNS)

8

a quick initial method of estimating how much of the client's skin surface is involved in a burn injury

"RULE OF NINES"

  • BE SURE TO LOOK OVER PERCENTAGES FOR EACH BODY PART FOR THE TEST!

9

What is the most accurate method of assessing TBSA?

LUND AND BROWDER METHOD

10

Initial first aid medical management for clients w/ burn injuries?

  • IF CLOTHING IS ON FIRE, CLIENT IS PLACED HORIZONTALLY ROLLED IN A BLANKET TO SMOTHER FIRE
  • LAY CLIENT FLAT
  • CLIENT IS TAKEN TO HOSPITAL FOR EXAMINATION
  • O2 AND IV THERAPY BEGINS

11

Acute care medical management for clients w/ burn injures?

  • MEDICAL TEAM ASSESS EXTENT OF BURN INJURY QUICKLY
  • MAINTAIN ADEQUATE VENTILATION AND INITIATE FLUID RESUSCITATION
  • VICTIMS OF CARBON MONOXIDE MAY REQUIRE HYPERBARIC OXYGEN TREATMENT
  • BLOOD SAMPLES ARE DRAWN
  • IV THERAPY (LACTATED RINGER'S AND OTHER COLLOID/CRYSTALLOID SOLUTIONS)
  • LOW DOES OF DOPAMINE TO ENSURE RENAL PERFUSION
  • IV ANALGESICS (MORPHINE)
  • TETANUS IMMUNIZATION

12

Wound management for clients w/ burn injuries?

  • REMOVE ALL OF THE CLIENT'S CLOTHES
  • HEALTH CARE PROVIDERS WEAR POWDER FREE STERILE GLOVES TO REDUCE ACCUMULATION OF DEBRIS
  • BURNED AREAS ARE CLEANSED TO REMOVE DEBRIS
  • AFTER CLEANSING, TOPICAL ANTIMICROBIAL MEDS ARE APPLIED
  • WOUND IS EITHER LEFT UNCOVERED OR COVERED
  • WOUND IS THEN COVERED W/ A SKIN GRAFT OR SKIN SUBSTITUE OR APPLYING CULTURED SKIN

13

Exposure method

  • exposes the burned areas to air
  • virtually abandoned since the advent of effective topical antimicrobials
  • client is placed in isolation in a bed w/ sterile linen; healthcare members and visitors wear sterile gowns an masks;
  • skin of client is sensitive to drafts and temperature changes; therefore, a bed cradle or sheets are placed over client
  • room is kept warm and humidified
  • ESCHAR HAS TO BE REMOVED; PRONE TO INFECTION

OPEN METHOD

14

Current preferred method of wound management b/c it creates a microbial barrier, reduces heat loss through evaporation, provides a moist environment that facilitates healing

  • burn area is covered w/ nonabsorbent or absorbent dressings; gauze is impregnated w/ petroleum jelly or topical antimicrobials in solution cream, or ointment-based compounds
  • final covering is an occlusive or semi-occlusive dressing that is minimally permeable to water and oxygen
  • MAKE SURE DRESSING IS NOT TIGHT!!

CLOSED METHOD

15

Medications that help treat burns:

  • MUPIROCIN
  • BACITRACIN
  • SILVER NITRATE
  • SILVER SULFADIAZINE
  • ALL DRUGS ARE APPLIED USING STERILE TECHNIQUE!!!!

16

Removal of necrotic tissue

  • potentially painful and warrants premedication w/ an analgesic
  • disadvantage is bleeding, which can lead to secondary healing due to low RBC counts
  • tissue is to be covered w/ antimicrobial dressing, temporary skin substitute, skin graft, or cultured skin

Wound debridement

17

When a wound dressing alone is no longer appropriate for covering large areas of burn tissue, these may become advantageous?

  • SKIN SUBSTITUTE
  • SKIN GRAFTING

18

Purposes of a skin substitute or graft?

  • lessen the potential for infection
  • minimize fluid loss by evaporation
  • diminish pain
  • promote regeneration of tissue
  • reduce scarring
  • prevent loss of function

19

graft obtained from animals (pigs or cows)

  • temporarily used to cover large areas
  • rejected by the body in days to weeks and must be removed and replaced at that time

XENOGRAFT

20

Biologic source of skin similar to that of a client

  • may be obtained from a cadaver, from human donor cells, or amniotic membranes
  • can be rejected by the body

ALLOGRAFT

21

Uses the client's own skin, which is transplanted from one part of the body to another

AUTOGRAFT

22

What are the DISADVANTAGES for a client harvesting their own tissue?

  • IT COMPOUNDS THE CLIENT'S PAIN B/C IT CREATES A NEW WOUND
  • DONOR SITE HAS THE POTENTIAL FOR SCARRING AND ATYPICAL PIGMENT CHANGES
  • THERE IS A POTENTIAL FOR DONOR SITE INFECTION
  • THERE IS A DELAY IN WOUND CLOSURE WHILE WAITING FOR THE DONOR SITE TO HEAL AND BE REHARVESTED
  • DELAYS CAUSED BY WAITING FOR HARVEST SITES TO HEAL INCREASE COSTS AND CHALLENGE THE CLIENT'S ABILITY TO COPE W/ PROLONGED HOSPITALIZATION

23

Nursing management for clients w/ burn injuries?

  • assess the wound and determine how the burn injury has affected the client's status
  • calculate fluid replacement requirements and infuses the prescribed volume according to the agency's protocol
  • s/s of shock are quickly recognized and efficiently tx'd
  • administer analgesics to relieve/reduce pain
  • wound is cleansed, an antimicrobial agent is applied, wound is covered w/ prescribed dressing
  • monitor the wound to determine any infection
  • client and family are supported
  • encourage the client to perform exercises that minimize contractures
  • encourage adequate nutrition and provides supplements as ordered
  • before discharge, the nurse teaches the client about the use of pressure garment and methods for skin care

24

REVIEW CLIENT AND FAMILY TEACHING 66-1: USE OF A PRESSURE GARMENT

REVIEW CLIENT AND FAMILY TEACHING 66-1: USE OF A PRESSURE GARMENT

25

When should client be weighed w/ burn injuries?

Client should be weighed daily and sufficient fluid added to reflect the fluids lost in weight change