Cheatography
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Nursing School education on burns
This is a draft cheat sheet. It is a work in progress and is not finished yet.
What are burns caused by?
- Burns are injury caused by direct damage to tissue from exposure to: |
1. Sun |
2. Chemicals |
3. Thermal (e.g.. Fire or burning liquids) |
4. Electricity |
Thermal Burns
MOST COMMON |
Due to exposure to dry heat (flames) or moist heat (steam, hot liquids) |
Severity depends on how hot it was and how long it was in contact with skin. |
Chemical Burns
Dangerous chemicals are found in homes and businesses. |
Acid, chem. to unclog sinks, cement, cleaners |
May cause local tissue damage or system tox. |
NURSING IMPLICATIONS |
Remove chemical from contact with the skin ASAP |
1.Remove nonadherent clothing. |
2. Flush chem from wound ASAP. |
Electrical Burns
"Iceberg effect" {Severity is diff to determine since most damage occurs under the skin. |
Priority: Manage Airway |
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Affects & Assessments... |
Heart |
Life threatening dysrhythmias or Cardiac Arrest.... Heart monitor |
Muscles and Bones |
Fractures. Electrical current can cause muscle contractions strong enough to fracture long bones and vertebrae ___________________ Stabilize Cervical Spine to prevent further injury. Assessment of extremity movement will provide baseline data. |
Rhabdomyolysis: Muscle tissue breakdown that results in the release of a protein (myoglobin) into the blood which can damage kidney |
Kidney Failure |
Myoglobinuria due to Rhabdo. {Damaged muscles release myoglobin and damaged RBCs release hemoglobin Myo & Hemo block tubules. AKI, acute tubular necrosis. |
Myoglobinuria indicated w/ dark urine. |
Rhabdo > Myoglobinuria > AKI & ATN |
Monitor Urine output (Kidney Function) ___________Adequate U/O during emergent phase: 0.5 to 1 mL/kg/hr___________________ IV Fluids |
Renal failure can occur in full-thickness burns as well |
Metabolic Acidosis |
Metabolic acidosis due to cellular hypoxia and increasing breakdown in renal and hepatic function. Can lead to shock or death. Can treat w/ IV sodium bicarbonate. |
Classification of Burn Injury:
Depth of burn |
% of TBSA |
Location |
Assoc. Injuries |
Pre-existing |
Degrees of burns (depth of burn damage)
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1st Degree (superficial) affects the top layer of the skin (epidermis)
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2nd Degree (partial-thickness) can be superficial or deep partial-thickness affecting various layers of the dermis.
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3rd Degree (Full-thickness) all skin layers are damaged along with the hair follicles, sweat glands, and nerves.
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4th Degree (deep full-thickness) worst of all. All layers are destroyed but it extends to the muscles, bone, and ligaments... all sensation of pain is gone.
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Eschar is another name for full-thickness nonviable burn tissue.
Lund-Browder chart (more accurate)
Rule of Nines (Used for initial assessment)
Risks with locations of burns
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Face, neck, circumferential torso -May interfere w/ gas exchange. (Leathery eschar, edema) - Circumferential extremity burns can impair fusion distal to the injury. (Monitor Pulses)
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Hands, feet, joints -Limit mobility and function.
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Ears, nose, buttocks, perineum -High risk for infection
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Risks with Preexisting Health Issues:
Pre-ex. heart, lung, or chronic diseases |
- contribute to poorer prognosis |
DM & Peripheral vascular disease |
- high risk for delayed healing |
Prehospital & Emergency Care
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1. Scene safety is a priority. |
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2. Remove from source of burn and stop burning process. - Flushing wounds w/ copious amounts of water minimize depth of injury.
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3. Wrap in dry, clean sheet or blanket. - This prevents wound contamination and provides warmth. Moist dressing can reduce pain but may cause hypothermia.
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4. Pt. may have other injuries that are priority over burn! |
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5. EMS must fully explain injuries. - Any hazardous chemicals involved or any Traumatic injuries (e.g., fall)
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Stages of Burn Assessment/Care
1. Emergent/Resuscitative Phase |
24-48 hours. |
2. Acute Phase |
48-72 hours/wound starts to heal. |
Starts w/ diuresis - Ends w/ closure of wound |
3. Rehab Phase |
May be years. |
Begins w/ wound closure - ends w/ patient at highest level of functioning. |
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