VIII.

BURNS
A. Occurance:
-The risk of death increases in the very ____________ and the very __________________.
-Where do most burns occur?
B. Pathophysiology:
-After a burn many different pathophysiological changes occur. WHY?
-Why does plasma seep out into the tissue?
-Increased ___________________permeability
-When does the majority of this occur?
Burns

-Why does the pulse increase?

-Anytime you're in a ______, the pulse will ________________
-Why does the cardiac output decrease? Less ___________ to pump out.
-Why does the urine output decrease?
-Kidneys are either trying to ________ on to fluid or they aren't being __________.
-Why is epinephrine secreted?
-Makes you ___________________, shunts blood to vital organs
-Why are ADH and aldosterone secreted?
-Retain __________ & _____________ with aldosterone and
-Retain _____________with ADH
-Therefore, the blood volume will go_________________.
C. Miscellaneous Information:
1. Airway Injury:
-What is the most common airway injury? ________________
______________poisoning
-Normally, oxygen binds with__________________. Carbon monoxide can run
much faster than oxygen . . . . Therefore, it gets to the hemoglobin first and
bindsCan oxygen bind now? yes or no
-Now the client is ______________.
-Tx: ________________________
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Carbon monoxide poisoning cannot be determined with O2 saturations; the sat monitor picks up
anything that is bound to hemoglobin so if carbon monoxide is bound to the hemoglobin then the
O2 saturation may appear normal so, the SpO2 may show 100% but the client STILL needs
oxygen due to the carbon monoxide poisoning.
Carboxyhemoglobin: blood test to determine carbon monoxide poisoning
Client will have cherry red skin coloring but they still need oxygen.

Least
Invasive
FIRST

-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? __________________________
2.Classification of Burn Injury:
-A client is burned over 40% of their body. How do you think this is determined?

Burns

*Estimate of Total Body Surface Area

D. Tx:
1. Fluid Replacement:
-One of the most important aspects of burn management is _________
_______________.
-Is it important to know that the burn occurred at 11:00 p.m.?
-Why? Fluid therapy (for the first 24 hours) is based on the time the injury ________,
not when treatment was ______________.
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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 requirements for the first 24 hours after burn

1st 8 hours = of total volume

2nd 8 hours = of total volume
3rd 8 hours = of total volume

NO matter what formula the doctor uses

The formula will tell the amount of fluid the client will get per hour
This client may be receiving as much as 500 ml/hr or more!

Burns

-To calculate fluid replacement properly you also need to know the clients
_________ (in kilograms) and TBSA affected.
* l kg = 2.2 pounds
-If the client is restless does it mean fluid replacement is inadequate, pain, or
hypoxia?
*Nurses Priority: ___________________
-Which of the following would you choose to determine if a clients fluid volume is
adequate? Their weight or their urine output?
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 had stopped?
-What else could have been done to stop the burning process?
-The blanket helped byHolding in the _________________ and kept out
__________.
-Jewelry?
-Airway injury?
-Do you think there is more death with upper or lower body burns?
-A clients respirations are shallow. You know they are retaining what?
_____________
-Therefore, which acid-base imbalance will they have?

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3. Medication Management:
a. Albumin:
-It is not uncommon for albumin to be given after a major burn, but not in the
first 24 hours.
-You know that albumin holds onto ______________ in the
_______________space.
-Vascular volume?
-Kidney perfusion?
-BP?

Burns

-Cardiac output?
-Will this help correct a fluid volume deficit?
-When you start giving a client albumin, you know that the vascular
volume will _____________.
-Therefore, what will happen to the work load of the heart?
-If you stress the heart TOO MUCH the client could be thrown into
fluid volume ________.
-If this occurs, what will happen to CO?
-Lung sounds?
-In a client who is receiving fluids rapidly, what you could measure hourly (hint:
heart) to ensure youre not overloading the client?
b. Pain Management:
-A client has an order for morphine that states: Morphine 5mg IVP or
Morphine 10mg IVP Q 2 hours prn pain. If the client is complaining of pain
(4/10) what dosage would the nurse give to the client?
-Why are IV pain meds preferred over IM with burns?

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c. Immunizations:
-Why is the client given a tetanus toxoid plus the immune globulin?
1) Tetanus Toxoid:
*takes 2-4 weeks to get the antibodies

(________ immunity)

2) Immune globulin: think ___________protection

immunity)

(________

If client is immune suppressed in any way (elderly, poor nutrition), if they have leukemia, on chemotherapy drugs,
or HIV positive, or on prednisone, the physician may withhold the tetanus shot because they could develop tetanus.
If they have an uncertain history of last tetanus shot, the client will also be given immune globulin.

E. Complications:
1. Circulatory System:

-If a clients vascular checks in this arm are bad the doctor may do what procedure to
relieve pressure?
-escharotomy which will relieve the ______________ and restore the
____________, cut through the eschar
-fasciotomy- which will relieve the _______________and restore the
_________________, but the cut is much deeper into the tissue, cut goes through the
eschar and the fascia
2. Renal System:
-A foley catheter was inserted so you could 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?
-What drugs might be ordered to flush out the kidneys?
-If there is no urine output or if it is less than 20ml/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 _________.
-Urine output?
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Burns

-A client has a circumferential burn on their arm.

-What does this mean? _______________________
-What should you be checking? ___________________________

3. Electrolyte Imbalances:
-The clients serum K+ level is 5.8.
-K+ likes to live inside OR outside of the cell?
-With a burn, what happens to cells?
-So, what happens to the number of K+ in the serum (vascular space)?
-Electrolyte imbalance? hypokalemia OR hyperkalemia
4. GI System:
-Why do you think Carbonate/Magnesium Carbonate (Mylanta), Pantoprazole
(Protonix), and Famotidine (Pepcid) are ordered?

Burns

Antacids: Aluminum Hydroxide Gel (Amphogel), Magnesium Hydroxide (Milk of Magnesia)

H2 Antagonist: Ranitidine (Zantac ), Famotidine (Pepcid), Nizatidine (Axid )
Proton Pump Inhibitors: Pantoprazole (Protonix ), Esomeprazole (Nexium)

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

-If a client doesnt 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 could you measure to ensure that the supplement
was moving through the GI tract ok?

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-What is some lab work you could check to ensure proper nutrition and a positive
nitrogen balance?
Pre-Albumin is a protein with a 2-day half life that reflects your nutritional status.
Normal Lab Value: 17-40 mg/dL
Albumin testing is more often used to test for liver or kidney disease or to learn if your body is not absorbing enough amino
acids. Albumin can also be used to monitor nutritional status (the client is not eating enough protein or has a low protein
diet). Albumin has a half life of 21 days.
Normal Lab Value: 3.4 to 5.4 g/dL
However, pre-albumin changes more quickly because of its short half life, therefore; it can be used to detect short-term
nutritional status quicker than albumin.

5. Integumentary System:
a. Contractures:
Burns

-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
-Since they have burns on their hands, what are some specific measures that may
be taken?
-Neck?
b. Infections:
-With a perineal burn, the #1 complication is___________________
-What is eschar?
-Does it have to be removed?
-If its not removed can new tissue regenerate?
-What likes to grow in eschar?

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c. Tx:
-What type of isolation will you use with the client?
-Sutilanis (Travase) or Collagenase (Santyl ): enzymatic drug eats dead
tissue
-Dont use on face

-Dont use over large nerves

-Dont use if pregnant

-Dont use if area opened to a body cavity

-Hydrotherapy is also used to ____________________.

Burns

Common drugs used with burns:

a. Silver Sulfadiazine (Silvadene)-soothing, apply directly, if rubs off 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 drugs be alternated?
-Broad spectrum antibiotics are avoided to prevent _________________________.
-Broad spectrum antibiotics will be used until the wound cultures have returned.
When giving-mycin drugswe WORRY when the clients BUN or creatinine increases or if the client complains
of any hearing loss because-mycin drugs can lead to ototoxicity (irreversible hearing loss) and/or nephrotoxcity.

d. Grafting:
-If grafting is done, a pressure dressing will be applied (to the donor site) in
surgery.Then when the bleeding has stopped the wound will be left open to air.
-If the skin graft should become blue or cool what would this mean?
-Sometimes the doctor 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?

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e. Chemical and Electrical burns:

1) Chemical burn?
2) Electrical burn 2 wounds. What are they?
-Electrical injury?
-What arrhythmia is this client at high risk for?
-With electrical burns _______can build up and cause _________ damage.
-It is not uncommon for this client to 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?
Burns

-Other complications of electrical wounds: cataracts, gait problems, and just

about any type of neurological deficit.

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