III.

BURNS

A. Occurrence:
Where do most burns occur?

B. Pathophysiology:

 After a burn many different pathophysiology changes occur.

1. Why does plasma seep out into the tissue?

Increased ___________________________ permeability

2. When does the majority of this occur? _________________________

Burns
3. When does the pulse increase?
Anytime you’re in a ____________, the pulse will __________________

4. Why does the cardiac output decrease? Less ___________ to pump out.

5. Why does the urine output decrease?

Kidneys are either trying to _______on to fluid or they aren’t being ______________.

6. Why is epinephrine secreted?

Makes you _________________________, shunts blood to vital organs

7. Why are ADH and aldosterone secreted?

Retain _______________ & ______________ with aldosterone and

Retain _______________ with ADH

Therefore, the blood volume will go _______________.

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 21
 C. Miscellaneous Information:
1. Airway Injury:
 What is the most common airway injury? ____________ ____________ poisoning
 Normally, oxygen binds with ___________________. Carbon monoxide travels
much faster than oxygen…. Therefore, it gets to the hemoglobin first and
binds….Can oxygen bind now? Yes or No
 Now the client is _____________________.
 Tx: ________________________________
 From this information, do you think it would be important to determine if the burn
occurred in an open or closed space?
 When you see a client with burns to the neck/face/chest you had better think what?
___________
*What might the physician do prophylactically? _________________________
Burns

*TESTING STRATEGY*
2. Classification of Burn Injury: Least invasive first
 A client is burned over 40% of their body. How do you think this is determined?
Estimate of Total Body Surface Area
 A common formula is called the _______________________________________.

22 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
 D. Tx: Clients with burns > 20-25% TBSA
1. Fluid Replacement:

 One of the most important aspects of burn management is _____________________

 Is it important to know what time the burn occurred?___________________

 Why? Fluid therapy (for the first 24 hours) is based on the time the injury
___________, not when the treatment was ______________________.

Common rule: Calculate what is needed for the first __________ hours and give half of
the volume calculated during the first 8 hours. This is the __________________Formula.

Parkland Formula
(4ml of LR) X (body weight in kg) X (% of TBSA burned) = total fluid requirement for the first 24 hours after burn

Burns
1st 8 hours = ½ of total volume
2nd 8 hours = ¼ of total volume
3rd 8 hours = ¼ of total volume

 To calculate fluid replacement properly you also need to know the client’s
___________ (in kilograms) and TBSA affected. *1 kg = 2.2 pounds

 If the client is restless it could suggest three problems: inadequate fluid replacement,
pain, or hypoxia.

*Nurse’s Priority: ___________________

*TESTING STRATEGY*
Pain never killed anyone.

 Which of the following would you choose to determine if a client’s fluid volume is
adequate? Their weight or their urine output? _______________________

NCLEX® Critical Thinking Exercise:

A client weighing 235 lbs. has a 30% total body surface area burn. The primary healthcare provider’s
order is: Titrate IV fluids to maintain urinary output at 0.5 ml/kg/hr. What is the desired output?
Record your answer as a whole number. ____________________________________________

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 23
 2. Emergency Management:
 A client was wrapped in a blanket to stop the burning process. Since the flames are
gone does that mean the burning process has stopped? ________________

 What else could have been done to stop the burning process? __________________

 The blanket helped by…Holding in the _____________ and kept out

_____________

 Remove jewelry? Because ________________ will occur, also metal gets hot.

 Clothing? Remove non-adherent clothing and___________ with a clean dry cloth.

 Signs of airway injury:

Burns

 Do you think there is more death with upper or lower body burns?

 A client’s respirations are shallow. You know they are retaining what? ________
Therefore, which acid-base imbalance will they have? __________________

3. Medication Management:
a. Albumin:
 You know that albumin holds onto ______________ in the __________________
space.

 Vascular volume?

 Kidney perfusion?

 BP?

 Cardiac output?

 Will this help correct a fluid volume deficit? ________ Because we are putting
more fluid where? _______________

 When you start giving a client albumin, you know that the vascular volume will
_________________________.

24 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
  Therefore, what will happen to the workload of the heart?

 If you stress the heart TOO MUCH:

The client could be thrown into a fluid volume ________________

If this occurs, what will happen to Cardiac Output?

Lung sounds?

In a client who is receiving fluids rapidly, what is a measurement you could take
hourly (hint: heart) to ensure you’re not overloading the client? ______________

b. Pain Management:

 Give the ____________ amount of narcotics necessary to relieve someone’s pain.

Burns
 Why are IV pain meds preferred over IM with burns?

__________________________________________

__________________________________________

c. Immunization:

1) Tetanus Toxoid: (_____________immunity)

*takes 2-4 weeks to develop their own immunity

2) Immune globulin: think ___________________ protection

(____________ immunity)

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 25
 E. Complications:
1. Circulatory System:

 A client has a circumferential burn on their arm.

What does this mean? ________________________________

What should you be checking? __________________________________

 If a client’s vascular check in their arm is bad what is the name of the procedure
to relieve pressure?

Circulatory check: Escharotomy- relieves the ___________ and restores the circulation, cuts
through the eschar.
1. ___________
2. ___________ Fasciotomy- relieves the pressure and restores the
Burns

________________________, but the cut is much deeper into the tissue,

3. ___________ cut goes through the eschar and the fascia.
4. ___________

2. Renal System:
 A Foley catheter is inserted to measure urine output.
How often will this need to be monitored?

 Is it possible that when you insert the catheter that no urine will return?

Why? Kidneys are either attempting to ___________ the fluid or they are not
being _______________________ adequately.

 What would you do if the urine was brown or red? Call the _______________

 What drug might be ordered to flush out the kidneys? ___________________

 If there is no urine output or if it is less than 30mL/hour, you would start

worrying about? _________________ __________________

 After 48 hours, the client will begin to diurese. Why? Because fluid is going
back into the _____________ space. Now we have to worry about fluid volume
_____________

 So what will happen to urine output now? ____________________________

26 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
 3. Electrolyte Imbalance:

 The client’s serum K+ level is 5.8

Where do we find most of our K+? _________________ the cell

 With a burn, what happens to cells? _________________________

 So, what happens to the number of K+ ions in the serum (vascular space)?
_________

 Electrolyte imbalance? Hypokalemia OR Hyperkalemia

4. GI System:
 Why do you think carbonate/magnesium carbonate (Mylanta®), pantoprazole
(Protonix®), or famotidine (Pepcid®) are ordered?

Burns
To prevent a _______________ _________________
Antacids: aluminum hydroxide gel (Amphogel®), magnesium hydroxide (Milk of
Magnesium®)
H2 Antagonist: ranitidine (Zantac®), famotidine (Pepcid®), nizatidine (Axid®)
Proton Pump Inhibitors: pantoprazole (Protonix®), esomeprazole (Nexium®)

 Why do you think the physician wants the client to be NPO and have an NG tube
hooked to suction?

Because they could develop a _____________________________

Why?
 Decreased vascular volume
 Decreased GI motility
 Hyperkalemia

If a client doesn’t have bowel sounds, what will happen to the abdominal girth?
_____________________________________

 Do you think the client will need more or less calories? _____________________

 The NG tube will be removed when you hear what? _______________________

 When you start GI feedings, what should you measure to ensure that the
supplement is moving through the GI tract? ________________________

 What is some lab work you could check to ensure proper nutrition and a positive
nitrogen balance? __________________, total protein, or albumin.

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 27
 5. Integumentary System:

a. Contractures:
Since the client has partial thickness and full-thickness burns, is it possible that
they could have problems with contractures? ______________________

Classification of Burns:

Superficial thickness: formally called first degree burn; damage only to epidermis
Partial thickness: formally called second degree burn; damage to entire epidermis and varying
depths of the dermis.
Full-thickness: formally called third degree burn; damage to entire dermis and sometimes fat

 If they have burns on their hands, what are some specific measures that may
be taken?
Burns

Wrap each ________________ separately.

Use _______________ to prevent contractures.

 __________________ the neck, head is back

No pillows, promotes chin-to-chest

b. Infections:

 With a perineal burn, the #1 complication is _______________________.

 What is eschar? _________________ _________________

 Does it have to be removed? ________________

 If it’s not removed can new tissue regenerate? _______________________

 What likes to grow in eschar? ___________________________

28 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
 c. Tx:
 What type of isolation will you use with the burn client? _____________________

 sutilanis (Travase®) or collagenase (Santyl®): enzymatic drug→ eats dead tissue

Don’t use on face

Don’t use if pregnant
Don’t use over large nerves
Don’t use if area is opened to a body cavity

 Hydrotherapy is also used to _______________________.

Give them pain medication prior to hydrotherapy
Worry about cross contamination

Burns
Common drugs used with burns:
a. silver sulfadiazine (Silvadene®)- soothing, apply directly, if it rubs off
a apply more, can lower the WBC, can cause a rash
b. mafenide acetate (Sulfamylon®)- can cause acid base problems, stings, if
it rubs off apply more
c. silver nitrate-keep these dressings wet; can cause electrolyte problems
d. povidone-iodine (Betadine®)-stings, stains, allergies, acid-base problems

 Why should these antibiotic drugs be alternated?

Bacteria will build __________________ or ______________________.

 Broad spectrum antibiotics are avoided to prevent _____________________ or

________________________.

Broad spectrum antibiotics may be used until the wound cultures have returned.
 Always make sure that the cultures have been collected before you start the
antibiotics.
 When giving mycin drugs….we WORRY when the client’s BUN or creatinine
increases or if the client complains of any hearing loss. Mycin drugs can lead to
ototoxicity (irreversible hearing loss) and/or nephrotoxicity.
Check their BUN and creatinine; if they are increasing, assume they are nephrotoxic.

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 29
 d. Grafting:
 Remove the burned dead tissue until healthy tissue is seen.
 Good skin is taken from a healthy donor site and placed over the burned area.
 The donor site is an open wound, so a transparent dressing is applied until
bleeding stops.
 Then the donor site can be left open to air.
 If the client is well nourished, they can reharvest from the same donor site
every 12 to 14 days.
 If the skin graft should become blue or cool what would this mean?
___________________
 Sometimes the physician will order for you to roll sterile Q-tips over the graft
with steady, gentle pressure from the center of the graft out to the edges.
Why?
Burns

e. Chemical and Electrical burns:

1) Chemical burn? First remove the client from the chemical and begin
_____________.
How long do you flush? ______________________
2) Electrical burn→ 2 wounds. What are they? _____________ and __________
 What is the first thing you do for an electrical injury? ________________
How long? _______________ hours

 What arrhythmia is this client at high risk for?

 With electrical burns myoglobin and hemoglobin can build up and cause
____________ damage.
 The client may be placed on a spine board with a c-collar. Why?

Electrical injuries occur in ______________ places, muscle contractions

can cause fractures, and the force of the electricity can actually throw the
victim forcefully.
 Are amputations common? ___________ Why?

 Other complications of electrical wounds: cataracts, gait problems, and

just about any type of neurological deficit.

30 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.