nur 298 role transition midterm (2)

7/27/2019 NUR 298 Role Transition Midterm (2)

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NUR 298 Midterm

1. Characteristics of Burns according to depth (pg: 1720 57-1)a. Superficial Partial-Thickness (like 1st degree)

i. Causes1. Sunburn, low-intensity flash

ii. Skin involved1. Epidermis, maybe part of dermis

iii. SX1. Tingling, hyperesthesia, pain soothed by cool water

iv. Appearance1. Red, blanches, min or no edema, maybe blisters

v. Recuperative course1. Complete recovery w/in 1 week; no scarring2. Peeling

b. Deep Partial-thickness (like 2nd degree)i. Causes

1. Scalds, flash flame, contactii. Skin involved

1. Epidermis, upper dermis, portion of deeper dermisiii. SX

1. Pain, hyperesthesia, sensitive to cold air iv. Appearance

1. Blisters, mottled red base, broken epidermis, weepingsurface

2. Edemav. Recuperative course

1. Recovery in 2 to 4 weeks2. Some scarring and depigmentation, contractures3. Infection may convert it to full thickness

c. Full-thickness (like 3rd degree)i. Causes

1. Flame, prolonged exposure to hot liquids, electric current,chemical, contact

ii. Skin involved1. Epidermis, entire dermis, sometimes subcu., maybe

connective tissue, muscle, boneiii. SX

1. NO PAIN!!

2. Shock3. Hematuria, hemolysis4. Possible entrance/exit wounds

a. w/ electrical burniv. appearance

1. dry, pale white, leathery, charred2. broken skin w/ fat exposed3. edema



v. recuperative course1. eschar sloughs2. grafting needed3. scarring and loss of contour/function; contractures4. loss of digits/extremity possible

2. Phases of burns (1725)a. Emergent/resuscitative phase (24-48 hours)

i. From onset to fluid resuscitation completion1. Fluid resuscitation occurs in the 1st 24 hours

ii. Priorities1. First aid2. Shock prevention3. Prevention of resp distress4. TX injuries

b. Acute/intermediate phase (48-72 hours)

i. Beginning of diuresis to wound closureii. Priorities1. Wound assess, care, closure2. Preventing infection3. Nutritional support

c. Rehabilitation phase (can last for years)i. From wound closure to return of optimal level of

physical/psychosocial adjustmentii. Priorities

1. Prevention of scars, contractures2. Rehab (PT, OT, vocational)

3. Reconstruction surgery4. Psychological counseling

3. Fluid and electrolyte changes in the emergent phase of fluid resuscitation (172757-3) – STUDY CHART!!

a. Shock phaseb. Observation

i. Generalized dehydrationii. Reduction of blood volumeiii. Decreased UOP

1. plasma leaks thru damaged capillaries2. secondary to plasma loss, fall of BP, and diminished CO3. secondary to

a. fluid lossb. decreased renal blood flowc. Na+ and H2O retention d/t increased adrenocortical

activityd. Hemolysis of RBCs



e. Causes hemoglobinuria and myonecrosis or myoglobinuria

iv. K+ excess1. Massive cell trauma causes release of K+ into extracellular

fluid

v. Na+ deficit1. Lots of Na+ lost and in trapped edema fluid and exudatevi. Metabolic acidosisvii. Hemoconcentration

1. Elevated hematocrit

4. Acute phase fluid and electrolyte phase (1730 57-4)a. Fluid and electrolyte phase (state of diuresis)b. Lasts 48-72 hours

i. Observation1. Hemodilution

a. Decreased Hematocriti. Blood cell concentration is dilutedii. Loss of RBCs at burn site

2. Increased UOPa. Fluid shift into intravascular compartment increases

renal blood flow causing more urine3. Na+ deficit

a. Sodium lost w/ diuresis4. K+ deficit

a. Begins on 4th or 5th post burn day5. Metabolic acidosis

a. Loss of Na+b. Relative CO2 content increasesc. DVT is in the late acute stage (worry about this in this stage)

5. Antibacterial agents for burn wounds (1736 57-5)a. Silver sufadiazine 1% (Sivadene)

i. Water soluble cream1. Apply 1/16” 1-3 times/day

ii. Min. penetration of eschar iii. Watch for leukopenia 2-3 days after initiation of therapyiv. Formation of pseudo-eschar (proteinaceous gel) which can be

removed after 72 hoursb. Mafenide acetate 5-10% (Sufamylon)

i. Hydrophilic-based cream1. Apply think layer w/ sterile gloves 2 times/day and leave

open as prescribedii. Effective against gram-neg and gram-posiii. Diffuse easily thru eschar iv. 10% strength is agent of choice for electrical burns



v. Monitor ABGs and dc if acidosis occursvi. Premedicate PT d/t burning pain for 20 min after application

c. Silver nitrate 0.5%i. Aqueous solution

1. Apply to guaze dressing and place over wound. Keep

dressing wet but covered w/ dry gauze and dry blankets todecrease vaporizatioina. Remoisten q 2 hours and redress 2 times/day

ii. Bacteriostatic and fungicidaliii. Does not penetrate eschar iv. Monitor Na+ and K+

d. Acticoati. Effective against gram-neg and gram pos orgs/ some yeasts and

moldsii. Delivers uniform antimicrobial concentration of silver to burn wound

1. Moisten w/ sterile water only. Apply directly to wound. Cover

w/ absorbent secondary dressing. Remoisten q 3-4 hrs w/sterile water.iii. Do not use oil-based productsiv. May produce pseudo-eschar v. Can be left on up to 3-5 days

1. Artioat 7 can stay on 7 days w/out changing dressing

6. Complications in rehab phase of burn care (1746 57-6)a. Neuropathiesb. Heterotopic ossificationc. Hypertrophic scarring

d. Contracturese. Wound breakdownf. Gait deviationsg. Complex regional pain syndrome (previous reflex sympathetic dystrophy

[RSD])

7. Biogram – when it starts peeling, trim it – DO NOT PULL GRAPHS OFF

8. When does a burn becomes a major burn? Wa. When it’s more than 20-25%

9. Nutrition (1741)a. Why do we feed burn PTs?

i. Hypermetabolism (may last up to 1 year after burn injury) happensimmediately after a burn injury. The degree of response dependson:

1. Size of burn2. PT’s age3. PT’s body composition



4. PT’s size5. PT’s genetic response to insult

ii. PTs lose weight d/t their hypermetabolic state1. PTs use their own body fat stores to start the healing

process

2. One goal of nutrition mgt is to decrease or stop the catabolicprocell and promote protein anabolism which promoteswound healing.

b. Most important nutritional intervention is to provide energy and nutrientsto prevent infection and promote wound healing

c. Goal of nutritional support is to promote a state of nitrogen balance andmatch nutrient utilization.

10.The rule of ninesa. Estimated percentage of total body surface area (TBSA) in the adult

i. Head 9% total

ii. Torso1. Anterior 18%2. Posterior 18%

iii. Left arm 9%iv. Right arm 9%v. Left leg 18%

vi. Right leg 18%vii. Perineum 1%

11. How do we prevent contractures? (1738)a. “Grafting permits earlier functional ability and reduces wound

contractures”b. Found on: http://www.urmc.rochester.edu/Encyclopedia/Content.aspx?ContentTypeID=90&ContentID=P01754

i. Most second- and third-degree burns do cause some degree of scarring, but there are several things that can be done to minimizescarring and to reduce contractures, including the following:

1. Wearing a splint Sometimes, after a child has been burned, he/she will needto wear a splint on the joint to keep it straight and to helpprevent a contracture. Splints should be worn on top of thepressure garment.

2. Practicing range of motion exercises Range of motion (ROM) exercises help keep the musclesand joints of the burned limbs flexible. A physical therapist(PT) will teach you and your child how to do ROM, so youcan help in the healing process.



12.Always want to do quick dressing changes because they are very painfula. Pre-medicate PT

13.Wound cleaninga. Hydrotherapy

i. Temp of water is maintained at 37.8C (80F)ii. Temp of room b/t 26.6C and 29.4C (80-85F)

14.Dressing changes need to done quickly d/t paina. Pain mgt

i. Analgesics1. IV use during emergent and acute phases

a. Morphineb. Fentynal

15.Debridement - aseptic

a. Goals of debridement: to remove eschar (dead tissue)i. Natural1. Skin separates on its own

ii. Mechanical1. Surgical removal with scissors, scalpels, and forceps of

eschar a. Will have bleeding and pain

iii. Surgical1. Cut to viable tissue

a. Early excision is done before natural separation of eschar is allowed to occur

i. Bleeding is okiv. Chemical1. Topical enzymatic debridement agents

16.Cool a burn with cool water/cool towels

17.Smoke inhalationa. Assess airway 1st

18.Acute Renal Failure manifestationa. Oliguria

19.Compression stockings for burn PTsa. Wear continuously

i. Can be off for 1 hour within a 24 hour period

20.Burns occur mostly at homea. Elderly and young mostly at risk



21.Most important to prevent pain and infection in the Acute phase of burns

22.Info you need to gather with a burn PT so you can stage the burn and know howto treat it

a. Causative agent

i. Flame, scalding liquid, chemicalb. How it occurredc. Temp of agentd. Duration of contact with agente. Thickness of skin

23.Post-op change in LOC means profuse bleeding

24.1st systemic eventa. Fluid shift causes cardiac decrease (decreased cardiac output!!!)

i. Hemodynamic instability

25.In emergent phase (lasts 24-48 hours) d/t fluid shifts PTs can have airwayobstruction – watch for 2 days

26.Renal trauma – hematuriaa. Always do urinalysis

27.CT scan w/ contrast needs to be prehydrated w/ N-acetylsteine and sodiumbicarb (1323)

a. Administering N-acetylcysteine and sodium bicarb before and duringprocedures reduces risk of CIN (radiocontrast-induced nephropathy), but

prehydration w/ saline is most effective method to prevent CIN.

28.Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypoperfusion and organ hypofunction secondary todecreased cardiac output.

29.Unstable dialysis PTsa. Continuous dialysis

30.S/SX with kidney transplanta. Oliguria

i. Monitor urine output

nur 298 role transition midterm (2)

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