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Types of Burns

Types of Burns

Thermal, chemical, electrical, cold thermal, smoke inhalation

Why are chemical burns hard to manage

because they cause protein hydrolysis and liquefaction- damage continues after alkali neutralized (up to 72h), can injury liver/kidney

smoke inhalation majory predictor of mortality

1. Carbon monoxide poisoning, 2. Above glottis, 3. Below glottis

Carbon monoxide poisoning

inhaled CO displaces O2 leads to hypoxia, carboxyhemoglobinemia, death

CO treatment

100% humidified

Smoke above Glottis

thermally produced, hot air/steam/smoke, mucosal burns of oropharynx and larynx, mechanical obstruction can occur quickly,

Clues To smoke above glottis

facial burns, singed nasal hair, painful swallowing, hoarse, carbonaceous sputum, hx of burn in enclosed space, clothing burn around neck.

Consequences of smoke above glottis

Pulmonary edema 12-24h after= acute resp distress syndrome.

Electrical burns

coagulation necrosis, direct damage to nerves and vessels, causing tissue anoxia/death.

Severity

amount of V, tissue resistance, current pathways, surface area, duration of flow, current can pass through organs= death of organ, electrical sparks may ignite clothing= thermal and electrical burns.

iceberg effect

Difficult to assess damage below skin for electrical below

Stage 1 Burns

Superficial partial thickness burn-epidermis

Stage 2 Burns

deep partial-thickness-dermis

Stage 3 Burns

Full-fat

Stage 4 Burns

muscle, bone

Phases of burn management resuscitative

lasts 72h, primary concern hypovolemic shock/edema. Fluid and electrolyte shift= hypovolemic shock from shift of fluid out of blood vessel as a result of increased cap permeability,, decreases BP, elevated pulse

Sevre burns amt fluid lost

200-400mL/hr,

Manifestations emergent burns

shock, pain, hypovolemia, blisters, adynamic ileus, shiver, mental status.

Complications emergent burns

dysrhythmias, hypovelomeic shock, impaired circ, tissue ischemia, necrosis. Escharotomies.

Nursing management emergent burns

early endotracheal intubation, escharotomies, fiberoptic bronchoscopy, humid o2 100%. 2 large-bore IV

Parkland Formula

>15% of TBSA. parkland (baxter) formula (FLUID REQ= TBSA burned % x w (kg) x (4mL/Kg) of RL, ½ fluid in 1st 8h, 2nd ½ over next 16 h.

Wound care

delayed until ABC, fluid replacement established, cleansing, debridement.

Open method

topical antibiotic no drsg. Silver sulfadiazine to gauze. When open burns, staff wear hats, masks, gowns, gloves. Allograft or homograft hands/arms extended on pillows no pressure on ears, early ROM, routine Labs, tetanus routine, no systemic antibiotics only topical.

VTE prophylaxis

low heparin, compression devices. Early and aggressive nutritional support, hypermetabolic state= increase 50-100%, 5000kcal/day, colloidal sol’n

Acute (wound healing) mobilization

of extracellular fluid and subsequent diuresis, acute phase done when all burn covered by skin grafts/healed.

Labs

hyponatremia and water intoxication, hyperkalemia, muscle weakness, ECG changes

Wound care- enzymatic debridement, grafts left open- complication blebs. Dermatome harvest skin for grafts.

Pain management

continuous background pain and treatment induced pain- tx

Complication

skin/joint contractures.

Brain death/Brain arrest

Irreversible loss of capacity for consciousness with the irreversible loss of all brainstem functions

Bereavement

Sense of deprivation or loss, Happens in conjugation with grief

Mourning

Social customs and cultural practices that follow a death

Palliative care

An approach that improves the QOL of individuals and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological, and spiritual problems.

Goals of EOL

Provide comfort and supportive care during the dying process Improve the quality of remaining life Help ensure a dignified death

Hearing and Touch and Death

↓ Sensation ↓ Perception of pain and touch Hearing and touch are the last sensory system to disappear

Taste, Smell, and sight

↓ with disease progression Blurring of vision Sinking and glazing of eyes Blink reflex absent Eyelids remain half-open

Integument

Mottling on hands, feet, arms, and legs Cold, clammy skin Cyanosis on nose, nail beds, knees “Waxlike” skin when very near death

Respiratory

↑ respiratory rate Cheyne-Stokes respirations Inability to cough or clear secretions Grunting, gurgling, or noisy, congested breathing Irregular breathing-Slowing down to terminal gasps

Urinary

Gradual ↓ in urinary output Incontinent of urine Unable to urinate

GI

Slowing of digestive tract and possible cessation of function Accumulation of gas Distension and nausea Loss of sphincter control Bowel movement may occur before imminent death or at the time of death

MSK

Gradual loss of ability to move Sagging of jaw resulting from loss of facial muscle tone Difficulty speaking Swallowing can become more difficult Difficulty maintaining body posture and alignment Loss of gag reflex Jerking seen in clients on large amounts of opioids (myoclonus)

Cardio

↑ Heart rate Later slowing and weakening of pulse Irregular rhythm Decrease in blood pressure Delayed absorption of drugs administered intramuscularly or subcutaneously

Dying Meds

Opioids = Dilauded/morphine Midazolam and pain meds can be run slowly through PCA and SC set Midazolam (versed) Scopolamine

RENAL SYSTEM Subjective

pain, voiding, Gi, anemia, fever, chills, DM, HTN, prostate enlargemente

Kidney Pain

costovertebral angle, dull ache, if sudden distension- severe/sharp, N, V, diaphoresis, pallor, acute obstruction, pyelonephritis.

Bladder pain

suprapubic, dull continuous, intense w voiding, full bladder= severe. Urgency, straining. Cystitis, tumour.

Urethral Pain

costovertebral angle, flank, lower abd. Severe sharp, N, V, ureteral stones, stricture, edema, blood clot.

Dysuria

pain difficult urination

Anuria

<100ml/24h

Upper

pyelonephritis

Lower

cystitis, urethritis

DX UTI

hx, exam, cystoscope, urinalysis, urine culture

Uncomplicated UTI

adequate fluids, antibiotic (1-3d), recurrence reduction

Complicated UTI

repeated urinalysis, antibiotic (3-5d), consider 3-6m suppressive antibiotics, adequate fluids

Renal Calculi

calcium oxalate stones

Renal Calculi DX

urinalysis, Urine culture, ultrasound, cystoscopy, BUN, Creatinine, WBC, Urine pH

Intervention

lithotripsy

Implementation

no obstruction

Acute kidney injury

varying degrees, changes occur in 48hr

Cause AKI

hypovolemia-decreased renal blood flow, tubule damage, ischemia, glomerular filtrate leaks decreased

CKD

anemia, PTH increase, small kidneys

GFR CKD

<60mL/min for 3m+ (normal 125), up to 80% GFR lots until symptoms. >90 kidney damage

CKD S+S

headaches, decreased ability to concentrate urine, polyuria to oliguria, increased BUN/creatinine/bp, edema,

Chronic Uremia

nitrogen waste builds up

Hyponatremia

water retention= edema, HTN, CHF. Metabolic acidosis, anemia, ecchymosis,

TX hyperkalemia

insulin+ Calcium gluconate

Musculoskeletal Subjective Data

Pmhx, meds, surgeries, important health info, questions about joints, muscle, bones, self-care etc.

Musculoskeletal Objective Data

Physical exam (inspection, palpation, motion, muscle-strength testing, measurement)

Musculoskeletal Aged related changes

Atrophy of muscles Tendons shrink & harden Reduction shrink & harden Loss of height Joint activity & motion

Musculoskeletal Diagnostic Studies

Radiological studies, bone mineral density, radioisotope studies, endoscopy, mineral metabolism, serological studies Muscle enzymes, invasive procedures, miscellaneous

Osteoarthritis Risk Factors

Major- Age >65y Family hx of osteoporotic fracture Vertebral compression fracture Crohn's disease Primary hyperparathyroidism, tendency to fall, osteopenia apparent on radiograph, hypogonadism, early menopause Minor- Rheumatoid arthritis Hyperthyroidism Prolonged use of anticovulsants Low calcium intake

Osteoarthritis Diagnostic studies

Bone scan, CT, MRI, x-rays, blood studies, synovial fluid analysis

Osteoarthritis Collaborative Care

Managing pain and inflammation Preventing disability Drug therapy Managing and improving joint function

Osteoarthritis Nursing Management

Patients joint pain and stiffness (type, location, severity, frequency, duration)

Nursing Diagnosis

Acute & Chronic pain Insomnia Impaired physical mobility Self-care deficits Imbalanced nutrition

Osteoarthritis Collaborative Care

Maintain or improve joint function through a balance of rest and activity Use joint protection measures to improve activity tolerance Achieve independence in self-care and maintain optimal role Pain control

Osteoarthritis Nursing implementation

Health promotion Acute intervention Frequent complaints of QA clients includes pain, stiffness, limitation of function

Osteoarthritis Evaluation

Experience adequate amounts of rest and activity, achieve pain management, joint flexibility

Rheumatoid Arthritis

Joint destruction begins as early as first year of disease without treatment Flexion contractures and hand deformities Nodular myositis and muscle fiber degeneration Cataracts and loss of vision Later, cardiopulmonary effects

Rheumatoid Arthritis Collaborative Care

Care begins with a comprehensive program of education and drug therapy Physiotherapy helps maintain joint motion and muscle strength Occupational therapy develops extremity function and encourages joint protection A caring, long-term relationship with an arthritis health care team can increase client’s self-esteem and positive coping

Rheumatoid Arthritis Nursing Assessment

Important health information Recent infections, presence of precipitating factors of remission & exacerbations Use of aspirin, NSAIDs, corticosteroids, DMARDs Integumentary (keratoconjunctivitis) Cardiovascular (symmetric pallor and cyanosis of fingers, dysrhythmias, distant heart sounds, murmurs Respiratory (chronic bronchitis, TB, histoplasmosis GI (splenomegaly) Musculoskeletal (symmetric joint involvement with swelling, erythema, heat, tenderness and deformities Lymphadenopathy, fever

Rheumatoid Arthritis Symptoms

Rheumatoid Arthritis Nursing Managment

Good pain relief Min loss of functional ability of affected joints Nursing Diagnosis Chronic pain Impaired physical mobility

Rheumatoid Arthritis Nursing implementation

Health promotion (education focuses on symptom recongiition) Acute intervention (primary focus is reduction of inflammation, pain, maintenance of joint function)

Gout

Uric acid is the major end product of purine catabolism and is excreted primarily by the kidneys. Hyperuricemia may result from prolonged fasting or excessive alcohol drinking because of the increased production of keto acids, which then inhibit uric acid excretion

Gout Manifestations

Acute- may occur in one or more joints Chronic- multiple joint involvements

Gout Diagnostic studies

Serum uric acid levels

Gout Collaborative Care

Drug therapy Weight reduction Avoidance of alcohol and foods high in purine Prevention of formation of uric acid kidney stones and development of associated conditions such as hypertriglyceridemia and hypertension

Gout Nursing Management

Nursing interventions for patients with acute gouty arthritis include supportive care for the inflamed joints The nurse must avid causing pain to an inflamed joint by careless handling Bed rest may be appropriate, with affected joints properly immobilized

Effects of Aging Mouth

Teeth loosen, reduced circulation to gums, teeth darken and fracture Decreased output of salivary glands Decreased stimulation of taste buds

Effects of Aging Stomach

Atrophy of gastric mucosa Decreased secretion of hydrochloric acid Decreased bile secretion Decreased muscle tone and strength

Gastrointestinal Assessment Subjective data

Pmhx Appetite, dysphagia, food intolerance, abd pain, nausea and vomiting, bowel habits, nutritional assessment Meds Surgery and other Bowel patterns, diet Lifestyle habits

Gastrointestinal Objective data

Physical exam (mouth, abd, IPPA, rectum and anus) Vital signs Height and weight Emesis, amount, colour, consistency Stool, amount, colour, consistency odor Oral, abd, rectal assessment

Gastrointestinal Diagnostic Studies

Radiological Studies

Nausea and Vomiting Assessments

Determine underlying cause and treat Careful history (when vomiting occurs, precipitating factors, contents of emesis) Differentiate among vomiting, regurgitation, and projectile vomiting

N & V Clinical manifestations

Anorexia Fluid and electrolyte imbalances (K+) Metabolic Colour of emesis

N & V Collaborative care

Determine underlying cause and treat Careful history When vomiting occurs, precipitating factors, contents of emesis Drug therapy Nutritional therapy Non-drug precautions

Constipation

Decreased frequency of bowel movements Insufficient dietary fibre, inadequate fluid intake, meds Valsalva manoeuvres

Constipation Clinical Manifestations

<3 BM/wk, abd distention, decreased appetite, indigestion, sensation of incomplete evacuation, straining at stool, elimination of small-volume, hard, dry stools

Constipation Collaborative care

Meds: stepwise approach for laxative Hemorrhoids, perforation, fissures ###

Constipation Nutritional therapy

Dietary fiber and fluids Exercise, bowel routine