Major Burn Case Study Worksheet – Flashcards
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Front of the face
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4.5
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Back of the head
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4.5
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The whole head and face
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9
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Chest
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9
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Whole front side
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18
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Back
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9
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Whole upper and lower back
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18
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Anterior right arm
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4.5
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Posterior right arm
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4.5
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Posterior right forearm
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2.25
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Posterior and anterior right forearm
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4.5
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Whole right arm front and back
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9
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Anterior right leg
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9
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Posterior right leg
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9
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Posterior and anterior right leg
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18
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Anterior right upper leg
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4.5
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Genital area
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1
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Why would a pt be NPO upon admittance with a burn injury?
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In order to assess GI motility They will only be NPO initially, but may be longer if there are no BS heard upon auscultation
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Why are patients given morphine sulfate IV when they have been burned?
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It will help with decreased absorption from the muscles and stomach due to third spacing
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Why do you need to get hourly urinary output on a patient who has been burned?
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This is the most sensitive indicator of CO
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What kind of things will you see on an EKG?
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K+ changes MI Electrical burns
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How do you want to position the pt
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Extended position Position of comfort is the position of contracture
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What is physical therapy used for?
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Ambulation strengthens the muscles in order to reduce the risk of long term complications
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Depth of a superficial partial thickness burn
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The entire epidermis Has varying layers of the dermis
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Depth of a partial thickness burn
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Deeper into the dermis
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Depth of a full thickness burn
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Burn through the subcutaneous layer, muscle and into the bone or through the bone
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What is a sign that it is a full thickness burn?
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If the hair is easily plucked out of the skin
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What is the appearance of a superficial partial thickness burn?
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Red, dry, blanches, blisters
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What is the appearance of a deep partial thickness burn?
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Red, weepy(wet), edematous, blisters
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What is the appearance of a full thickness burn?
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Dry, leathery, hard, white/eschar, edema
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What is the pathophysiology of a burn injury?
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First there will be tissue damage histamine release(larger the burn the more the histamine release) increased capillary permeability(3rd spacing decreased CO decreased tissue perfusion
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What type of system alterations are there with burns?
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CV F&E Pulmonary Renal Immunologic Thermoregulatory Gastrointestinal
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Cardiovascular alterations
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Lasts 24-36 hours Increased capillary refill means that there is excessive fluid loss through the skin Decreased CO Can result in hypovolemic shock Anemia (they will have an increased HH)-->weird but this is because there is not a lot of fluid in their body therefore the HH is not well concentrated
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What kinds of treatments are there for the cardiovascular alterations that can occur?
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IV fluids Blood products in order to increase the HH
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Fluid & electrolyte alterations
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Edema -local to systemic -compartment syndrome -excessive fluid resuscitation Evaporation losses Hyponatremia Hyper-->hypokalemia
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What kinds of treatments are there for the fluid & electrolyte alterations that can occur?
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Calculate the amount of fluid the patient should be receiving Calculate the patients amount of hourly UOP Prevent evaporation losses by covering the wounds up Monitor and replace the patients electrolytes as needed
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Pulmonary alterations
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Upper airway -direct heat, edema -upper airway obstruction Inhalation injury -irritation from the gases (co) -atelectasis -carboxyhemoglobin Restrictive defects -eschar, edema to neck/chest -decreased tidal volume -respiratory distress
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What kinds of treatments are there for pulmonary alterations that can occur?
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Intubation Intubation, 100% O2 Escharotomy
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What is the Parkland formula
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This is a formula that is used to help figure out the patients fluid resuscitation needs for the first 24 hours 4mL X kg X %TBSA burned
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What is an appropriate nursing diagnosis for burns?
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FVD
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What types of signs and symptoms makes FVD the best nursing diagnoses for a burn patient?
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Tachycardia BP is low High HH High urine specific gravity
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What are the types of oral nutritional needs for a burn patient?
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High calorie, high protein foods Avoid empty calories Protein supplements Ask the patient what their food preferences are.. doesnt really matter what it is, the most important thing you can do is to make sure that they are eating lots of calories and protein
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What are the types of enteral nutritional needs for a burn patient?
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The patient will have a feeding tube if they are not able to eat the recommended calories to promote healing The feeding tube should be placed past the pylorus
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What types of evaluation are important, or what are some extra ways to care for the patient?
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Monitor the serum albumin and protein levels Calorie needs may be 3-4 times higher than normal Make sure to count the patients calorie intake, this way you can be sure they are getting enough carbs in Insulin drips may be administered to the patient in order to keep their BG levels down. Make sure that you write everything down for the dietician so they can be sure to not leave any nutritional goals out
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If the patient starts to loose a pulse and cannot be found by palpation or the use of a dopler. They also lose sensation and the foot turns dusky and cold. What might be going on with the patient?
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The patient is suffering from compartment syndrome
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What is the assessment that you do for circumferential burns?
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The 6 P's 1. Pulseless (absent or weak) 2. Pallor 3. Paresthesia (altered sensation) 4. Pain 5. Paresis (muscle weakness) 6. Poikilothermia (a cool limb)
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What is usually the type of thing that will help restore the 6 P's and is used for burns?
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Escharotomy
