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MedSurg II - Thermal Inj

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olanjones's version from 2017-03-28 05:11

Types

Question Answer
ThermalFlame, flash, scald, or contact w/ hot item (Severity depends on temp & duration)
ChemicalAcids, alkalis, and organic compounds (often splash inj – may include eye damage)
Why are alkali burns harder to txAlkalis adhere to tissue causing protein hydrolysis & liquefaction (oven/drain cleaner, fertilizers)
Smoke & InhalationHot air or noxious chemicals-damage to respiratory tract; Smoke inhalation injuries are major predictor of mortality in burn patients
Inhalation injuriesMetabolic asphyxiation (carboxyhemoglobin), upper/lower airway injury
ElectricalIntense heat generated from electric current; Direct damage to nerves/vessels causing tissue anoxia & death; Risk for dysrhythymias, cardiac arrest, metabolic acidosis, myoglobinuria (Severity depends of voltage, tissue resistance, current pathways, surface area in contact with current & length of time)
Most & Least resistance to electrical currentFat & bone - most resistance. Nerves & blood vessels - least resistance (current that passes through organs produce more life threatening issues)
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Classification

Question Answer
Depthdetermined by degrees according to skin depth destruction
Superficial1st degree (epidermis); Erythema, blanching on pressure, pain & mild swelling, no vesicles/blisters
Deep partial2nd degree (dermis); Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured) - Severe pain from nerve injury, mild-mod edema
Full thickness3rd & 4th degree (fat, muscle, bone); Dry, waxy white, leathery, or hard skin; visible thrombosed vessels - Insensitivity to pain d/t nerve destruction
Rule of 9sinitial assessment of % body burned (First-degree burns, equivalent to a sunburn, are not included when calculating TBSA)
Lund-BrowderBased on age in proportion to body size (considered more accurate)
Concern re: facial, neck, circumferential of back/chest burnsMay interfere w/breathing from edema/scars - may also suggest inhalation injury
Concern re: hand/feet burnsMay make self-care difficult (hard to manage due to superficial vessels/nerves)
Concern re: ears/noseMore susceptible to infection due to poor blood supply to cartilage
Concern re: buttock/perineum↑infection risk d/t urine/feces
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Pre-Hospital Care

Question Answer
Small thermal burnsCover w/ clean, cool, tap water-dampened towel
Burn >10% TBA, Electrical, Inhalation-Cool large burns for <10 min (hypothermia risk - never cover w/ ice-can ↓blood flow to area)
-Remove burned clothing (leave adherent)
-Wrap in clean sheet to protect from infection
Chemical burns-Remove chemical powder/particles
-Remove all clothing containing chemical –will continue to burn
-Flush affected areas w/ copious amounts of water (tissue damage may cont. ↑to 72 hours)
Inhalation injObserve for respiratory distress
What else must be considered in carePt may have other injuries that take priority over the burn
Emergent (Resuscitative) Phasetime required to resolve immediate, life-threatening problems resulting from burn injury; usu lasts ↑to 72 hours from time burn occurred
Primary concernsHypovolemic shock & edema
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Complications

Question Answer
Burn shockCapillary seal is lost, interstitial edema develops; cellular integrity altered, sodium moves into cell in abnormal amounts & potassium leaves cell. The water & sodium move back into the circulating volume through the capillary, the albumin remains in the interstitium
Cardiovascular-Dysrhythmias & hypovolemic shock may progress to irreversible shock
-Edema/circumferential burns act as tourniquet causing ischemia, paresthesia, necrosis
Escharotomyincision into full thickness eschar restores circulation to extremities
↑Blood viscositymay impair microcirculation
Respiratory PAY ATTN to people who feel impending doom/may not be able to breathe; Also risk for pneumonia & pulmonary edema
Resp EvalMay need bronchoscopy, carboxyhemoglobin level to evaluate inhalation injury (initial CXR may be nl)
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Management

Question Answer
Emergent Phase
(↑to 72 hrs)
Fluids, Wound care, Pain/anxiety, PT&OT (positioning/splinting), Nutritional, Respiratory, Psychosocial
Acute Phase
(weeks-months)
Fluids, Wound care, Early excision & grafting, Pain/anxiety, PT&OT (ROM, anticontracture assess, encourage self-care if poss), Nutritional, Respiratory, Psychosocial, Drug tx
Rehab Phase
(2 wks-8 mos)
Continue to: Counsel & teach, Encourage & assist in self-care, Prevent/minimize contractures and scarring (poss need sx, PT/OT), Discuss poss reconstructive sx, Prepare for d/c
Parkland (Baxter) Formula4 mL lactated Ringer’s solution per kilogram (kg) of body weight per % of total body surface area (% TBSA) burned = Total fluid requirements for first 24 hr after burn
Fluid resuscitation application½ of total in first 8 hr; ¼ of total in second 8 hr; ¼ of total in third 8 hr
AnalgesicsMorphine, hydromorphone, fentanyl, oxycodone & acetaminophen, methadone, NSAIDs, Adjuvant analgesics (gabapentin)
Sedatives/hypnoticslorazepam, midazolam, zolpidem
Antidepressantssertraline, citalopram
Anticoagenoxaparin, heparin
Nutritional supportVit A, C, E, & mvi; zinc, iron, oxandrolone
GI supportranitidine, esomeprazole, Mylanta, Maalox, nystatin
Partial thicknessPink-cherry red (may/may not have blisters), Painful when touched, Minor, localized sensation d/t nerve destruction - Debride using scissors/forceps to remove necrotic skin (Escharotomies/fasciotomies done in OR) Infection may cause further tissue damage
Escharotomyincision into full thickness eschar restores circulation to extremities
Open methodBurn covered w/ topical antimicrobial w/ no dressing
Closed/Multiple methodSterile gauze dressings impregnated with or laid over topical antimicrobial (changed every 12-24 hours or up to 14 days depending on product)
Use PPE whenwounds are open, use sterile gloves to apply ointment
Goalpermanent wound coverage (if >50% TBA may not be enough unburned skin for grafting)
GraftsEschar excised down to subq tissue/fascia (Day 1 or 2-wound covered with allograft, cadaveric, or biologic dressing until can permanent graft)
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PT/OT/Rehab

Question Answer
2 kinds of pain1. continuous background pain
2. tx induced pain (dressing change, ambulation, rehab)
Background painTx w/ opioid infusion, around the clock analgesics
Tx inducedTx w/ premedication prior to activites
What agreement should be made re: paindetermine what pts “tolerable” level is
Why is therapy IMPERATIVEto help pt maintain muscle strength & join function
When should therapy be doneAfter wound cleaning (skin is more pliable, dressings are off); Use both active & passive ROM
Why no pillow for neck burnsMay cause contractures; Encourage hyperextension by hanging head off HOB
New skin appearanceflat and pink; in 4-6 wks will become raised & hyperemic (ROM must be done)
How long does mature healing take12 months; pink color fades to lighter shade than unburned skin; Darker skin takes longer to regain color d/t loss of melanocytes
Pressure garmentsUsed to help scars from being raised
New skin sensitivitysensitive to trauma; may be hypersensitive to heat/cold; Will need water-based moisturizers for itching while skin heals
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