Care of Clients in Cellular Aberrations,

Acute Biologic Crisis (ABC), Emergency and Disaster Nursing

(NCM106)
Acute Biologic Crisis IV
Continuation of Lecture
BASIC LIFE SUPPORT
An emergency procedure that consists of recognizing respiratory
or cardiac arrest or both and the proper application of CPR to
maintain life until victim recovers or advanced life support is
available.
Knowledge Objectives:
1. Identify the three kinds of Life Support
2. Describe the primary functions of the respiratory,
circulatory and nervous systems.
3. Assess the condition of an accident.
4. Describe respiratory arrest.
5. Describe the ways in ventilating the lungs.
6. Describe cardiac arrest.

Skills Objectives:
1. Demonstrate how to provide rescue breathing for an adult who
shows signs of breathing inadequacy or absence.
2. Demonstrate how to provide cardiopulmonary resuscitation to an
adult with cardiac arrest

ADVANCED CARDIAC LIFE SUPPORT (ACLS):
The use of special equipment to maintain breathing and circulation for the victim of a cardiac emergency.
PROLONGED LIFE SUPPORT (PLS)
For post-resuscitation and long-term care.

CHAIN OF SURVIVAL







SCENE SURVEY
Is the scene safe?
What happened?
Know the mechanism of injury
Am I safe?
Necessary protections
Universal precautions
Can I help?
Number of patients
Others that can help

Primary Survey
Is the patient conscious?
Tap and shake the shoulders lightly.
Hey, hey, are you okay?
Is the airway open?
Head Tilt Chin Lift Maneuver (HTCL)

LOOKY
HERE
Topics Discussed Here Are:
1. Basic Life Support
2. Burns
a. Discussion on Burns
b. Systemic Changes in Major Burns
i. Fluids Shifts
ii. Hemodynamic Changes
iii. Metabolic Demands
iv. Renal Demands
v. Pulmonary Changes
vi. Immunologic Activity
vii. GI Impact
c. Assessment of Burns
d. Hemodynamic Stabilization
i. IV Fluid Therapy
ii. Metabolic Support
iii. Wound Cleansing and
Debridement
iv. Hydrotherapy
v. Topical Antimicrobials
vi. Biologic Dressings
e. Nursing Management of Burn Patients
f. Health Education of Burn Patients
Most commonly used method
Use the palm of one hand to apply firm, backward pressure on the victims
forehead while placing the fingers of the other hand on the bony part of the jaw
to bring the chin forward.
Modified Jaw Thrust Maneuver (MJT)
This is used when you suspect cervical spine injury.
Place your fingers at the angles of the victims jaw and lift the jaw without tilting the
head.
Is the patient breathing?
Look for the rise and fall of chest
Place your ears near the nose of the patient to listen for breathing
Check near the mouth of the victim to feel for air moving from the victims mouth
Does the patient have signs of circulation?
Check the carotid pulse
Check the capillary refill
Check for any movement
Check for coughing

ACTIVATE MEDICAL ASSISTANCE
- CALL FIRST
o If the patient is an adult
o The cause of the unconsciousness is NOT trauma (injury) or drowning
o The rescuer should assume that the victim has a heart problem and go for help when
unresponsiveness is established or after establishing unresponsiveness and the absence of
breathing
- CARE FIRST
o Cause of unconsciousness is trauma (injury) or drowning
o If the victim is a child or an infant
o The rescuer should perform resuscitation for about 1 minute before going for help.

RECOVERY
^ How do I position the victim if he recovers?
o Near a true lateral position as possible with the head depended to allow free drainage of fluid
o The position should be stable
o Any pressure on the chest that impairs breathing should be avoided
o It should be possible to turn the victim onto his side and return to the back easily and safely,
having particular regard for the possibility of cervical spine injury.
o Good observation of and access to the airway should be possible.
o The position itself should not give rise to any injury to the victim.

CARDIOPULMONARY RESUSCITATION
) The combination of external chest compressions and rescue breathing
o TYPES
1 rescuer CPR
2 rescuer CPR
Cough CPR
Compression Only CPR
) CRITERIA FOR NOT INITIATING CPR
o DNR
o Presence of irreversible death
Rigor mortis: 3 4 hours maximum stiffness at 12 hours
Livor mortis: Bluish discoloration
Algor mortis: Reduction of temperature after death
o Absence of physiological benefit
Septic
Cardiogenic Shock
o Severe mutilation
) WHEN TO STOP
S Spontaneous signs of circulation are restored
T Turned over to medical services
O Operator is already exhausted and cannot continue CPR
P Physician assumes responsibility over the victim
CPR: COMPRESSIONS
* AREA
o Lower half of the sternum
o Middle of the chest, between nipples
* DEPTH
o 1 to 2 inches
* COMPRESSION-VENTILATION RATION
o 30:2
Pump hard and pump fast
Consists of rhythmic applications of pressure over the lower half of the sternum.
These compressions create blood flow by increasing intrathoracic pressure and directly compressing the
heart.

RESCUE BREATHING
A technique in breathing into another persons lungs to supply him with oxygen needed to survive.

RESPIRATORY ARREST
E Victims whose respiratory stops but whose
circulation or pulse is still present.
E Causes:
Obstruction
Disease
Other Causes
Electrocution
Drowning
Poisoning
Circulatory collapse
Chest compressions
E Objectives
To open airway
Head tilt Chin Lift
Jaw Thrust
To ventilate the lungs
Mouth to mouth
Mouth to nose
Mouth to mouth and nose
Mouth to face shield
Mouth to mask
Bag-Mask Device
To restore breathing
ADULTS:
- 1 slow flow
breath every five
seconds
- 24 cycles for 2
minutes
CHILDREN and
INFANTS:
- 1 slow breath
every 3 seconds
- 40 cycles for 2
minutes

BURNS
Burn is a traumatic injury caused by
Thermal
Electrical
Chemical or radioactive agents.
Inhalation injury and associated pulmonary complications (50%-60%)
Indicates a significant factor in mortality and morbidity of death
BURNS: Etiology and High risk individuals
Most accidents occur at home (Domestic Type)
(E.g. smoking with alcohol intake.)
Second to the list is at Work.
Very young and elderly are also at high risk.
Leading cause of Flame injury occurs at adults/school age.
E.g. playing with matches
Scalding nabanlian injury is common for children.
Teenage boys have a high incidence of electrical injuries.
Males are commonly injured by burns rather than female.
Smoking, combined with alcohol intake, is associated with at least half of major fire injuries and
deaths.

BURN INJURY
A burn injury usually results from energy transfer from a heat source to the body.
Types of burn injuries:
Flame/flash
Contact
Scald (water, grease)
Chemical
Electrical
Inhalation
Any thermal source

PHYSIOLOGIC REACTION OF THE BODY DURING BURN INJURY
1. Adjacent intact vessels dilate
o Causing redness and blanching with pressure.
2. Platelets and leukocytes begin to adhere to the vascular endothelium
o (Inflammatory process)
3. Increased capillary permeability
o Produces wound edema
4. Eventually, new capillaries, immature fibroblasts, and newly formed collagen fibrils appear within the
wound.
o This supports the regenerating epithelium or forms a granulating tissue bed to accept a skin
graft.

Types of Tissue Injury
Partial-thickness burn injuries
Full-thickness injuries
Partial-thickness burn injuries
+ Involve the epidermis
Upper portions of the dermis.
Some of the dermal appendages remain, from which the wound can spontaneously
re-epithelialize.
+ Full-thickness injuries
All layers of the skin
Sometimes underlying tissues are destroyed. At the core is the burn injury.
Grafting usually is required to close the wound.
Burn depth
Is directly related to the temperature of the burning agent
And the duration of contact with body tissue.

Types of Burn depth
Below 112 F (44.4 C): No local damage occurs unless exposure is for a protracted period.
At 120 F (48.9 C): It takes 5 minutes' exposure to create a full-thickness burn.
At 125 F (51.7 C): The time requirement is 2 minutes
At 140 F (60 C): Only 6 seconds are required.
At 159 F (70.6 C): It takes 1 second to create a full-thickness burn in a healthy adult less time or
temperature in children or the elderly.

INHALATION INJURY
May be upper airway (supraglottic)
May incur injury in minutes to hours
May involve the lower airway and cause acute respiratory distress syndrome (ARDS).
This can occur in as little as 4 hours.
ARDS is most simply described as pulmonary edema of noncardiac origin.
It may also be seen in children.
Carbon monoxide poisoning
Toxicity depends on concentration of carbon monoxide in inspired air
Length of time of exposure.
+ A carboxyhemoglobin level of less than 10%: Is not a cause for alarm
+ From 10% to 20% needs clinical supervision watching
+ Should be correlated with the spirometry results.
(Smokers have been known to have carboxyhemoglobin levels of 15% to 18 %.)
+ Levels of 20% to 50%
+ Signs and Symptoms:
Headache
Fatigue
Irritability
cardiac dysrhythmias
Ataxia
Vomiting
Syncope
tinnitus,
loss of consciousness
Dystonia
impaired judgment
deep coma
Hypotension
Seizures
respiratory arrest
Death- This is considered
a severe to lethal
exposure.

Sulfur Dioxide and Nitrous Oxide
+ Are toxic agents inhaled in soot (inflamed mucosa).
In the presence of water, they form corrosive acids and alkalis that are extremely toxic.
May alter mentation.
Toxic fumes from burning plastic are more dangerous than smoke.
+ Noxious gases include:
Hydrogen Cyanide
Hydrochloric Acid
Sulfuric Acid
Halogens
Perhaps phosgene.

Assessment for Inhalation Injury
If victim was burned in a closed area
There should be a high index of suspicion that smoke inhalation has occurred.
Evaluate all patients in closed-space fires for symptoms of carbon monoxide poisoning
Question the patient about types of things that burned in this room
Type of carpet
Vinyl articles
Synthetics
Observe for upper body burns erythema such as:
Blistering of lips
Buccal mucosa or pharynx
Singed nasal hair
Soot in oropharynx
Dark gray or black sputum
Listen for hoarseness and crackles: Are indicators of increasing need for intubation
Increasing hoarseness
Stridor
Drooling

LABORATORY TEST:
Obtain arterial blood gases (ABGs)
Carboxyhemoglobin levels
Spirometry
Direct visualization of the vocal cords may be necessary.
A chest X-ray should be obtained as a baseline.

Systemic Changes in Major Burns
e Major Burns involving more than 25% of total body surface area (TBSA).
o Fluid Shifts
o Hemodynamic Changes
o Metabolic Demands
o Renal Needs
o Pulmonary Changes
o Immunologic Activity
o GI Impact

Fluid Shifts
4 Changes in the local burned area
4 Alterations and disruptions in the vascular
4 The water-vapor barrier for the body is the outermost layer of epidermis.
o When it is rendered non-functioning, severe systemic reactions from fluid losses can occur.
4 Fluid volume deficit is directly proportional to the extent and depth of burn injury.
4 Capillary permeability increases
o Permitting fluid and protein to move from vascular to interstitial spaces (edema results)
First 24 to 36 hours, peaking at 12 hours post-burn.
Protein-rich fluid is lost in blebs of the burned tissues which may contribute to
EDEMA formation.
With reduced vascular volume
The patient will go into shock if untreated.
o Capillary permeability starts to change in about 48 hours, but protein lost in interstitial spaces
may remain there for 5 days to 2 weeks before returning to the vascular system.
When fluid mobilizes (interstitial spaces to vascular compartment)
Patients with good cardiac and renal function will diurese.
Patients with impaired cardiac or renal function are in danger of fluid overload
and pulmonary edema at this time.
o Red blood cell (RBC) mass is also diminished due to:
Thrombosis
Sludging
RBC death from thermal injury
4 As fluid escapes from capillary walls, however, blood concentrates and the hematocrit rises
o Causing sluggish flow.
4 Capillary stasis may cause ischemia and even necrosis.
4 The body attempts to compensate for losses of plasma volume.
o Constriction of vessels
o Withdrawal of fluid from undamaged extracellular space
o The patient is thirsty
Oral fluids are not given until bowel sounds are heard or until patient is no longer
intubated

Hemodynamic Changes
] Lessened circulating blood volume
o Results in decreased cardiac output initially
o Increased pulse rate.
o There is a decreased stroke volume as well as a marked rise in peripheral resistance
Due to constriction of arterioles and increased hemoviscosity.
] This results in inadequate tissue perfusion, which may in turn cause:
o Acidosis
o Renal Failure
o Irreversible burn shock.
] Electrolyte imbalance may also occur
o Hyponatremia: Usually occurs during the 3rd to 10th day due to fluid shift.
o Hyperkalemia: Initially due to cell destruction
o Followed by hypokalemia: As fluid shifts occur and potassium is not replaced.

Metabolic Demands
+ Catecholamine release
o Appears to be the major mediator of the hypermetabolic response to burn injury.
+ Burn fever
o Usually seen during the first week post injury
o Is common and is dependent on depth of burn and percentage of TBSA involved.
o Temperatures of 102 F to 103 F (38.9 C to 39.4 C) are common as fever spikes
+ Healing a large surface area requires much energy
o Glucose is the primary metabolic fuel.
o Total body glucose stores are limited
Stored liver and muscle glycogen is exhausted within the first few days post-burn
Hepatic glucose synthesis (gluconeogenesis) increases.
+ Insulin levels decrease early post burn
o Patients develop hyperglycemia.
o Probably due to increased gluconeogenesis
o Skeletal and visceral protein is mobilized
To meet increased nutritional demands.
+ The adult burn patient may require 3,000 to 5,000 calories or more per day.
o Burns less than 10% TBSA: A well-balanced diet with emphasis on protein intake is
necessary.
o 10% to 20% TBSA: A high-protein, high-calorie diet is ordered.
o 20% to 30% TBSA: Supplementary enteral nutrition is necessary.
o 30% and 40% TBSA: TPN may be implemented.
However, the current trend is to meet nutritional needs enterally, if possible.

Renal Needs
Glomerular filtration may be decreased in extensive injury.
Decreased renal blood flow :
o May lead to high output or oliguric renal failure
o Decreased creatinine clearance
o Creatinine builds up

Pulmonary Changes
Hyperventilation and increased oxygen consumption are associated with major burns.
The majority of deaths from fire are due to smoke inhalation.
Effects of burn shock on cell membrane potential may cause pulmonary edema
o Contributing to decreased alveolar exchange.
o Inhalation injury: It may be necessary to keep the patient slightly less hydrated.

Immunologic Activity
The loss of the skin barrier and presence of eschar
o Favors bacterial growth.
Abnormal inflammatory response after burn injury
o Causes a decreased delivery of the ff:
Antibiotics
White blood cells
Oxygen to the injured area.
The following conditions impair host resistance to pathogenic bacteria
Hypoxia
Acidosis
Thrombosis of vessels in the wound area
Burn wound sepsis
o A bacterial count of 10 per gram of tissue as determined by burn wound biopsy
(quantitative culture) indicates burn wound sepsis.
o Usually, only a swab culture is done of the wound surface.
o The wound is fully colonized in 3 to 5 days.
o Seeding of bacteria from the wound may give rise to systemic septicaemia.

GI Impact
As a result of sympathetic nervous system response to trauma
: Peristalsis decreases
: Gastric distension
: Nausea & vomiting
: Paralytic Ileus may occur.
Ischemia of the gastric mucosa put the burn patient at risk for duodenal and gastric ulcers
Signs and Symptoms:
: Occult bleeding
: In some cases, life-threatening hemorrhage.

SEVERITY OF BURNS
Severity of burns is determined by:
Depth: First, Second (Partial Thickness), Third degree (Full Thickness).
Extent: Percentage of TBSA.
Age: The very young and very old have a poor prognosis; the prognosis alters for adults after age 45.
Area of the body burned:
Face, hands, feet, perineum, and circumferential burns require special care.
Medical history and concomitant injuries and illness\
Inhalation injury

Assessment for the Extent of Body Surface Burned
Anatomic location burns affecting
- Hands
- Feet
- Face
- Perineum
Require specialized care.
Circumferential burns also require special attention, possibly escharotomy.
Repeat assessment may be performed on the second or third day to verify demarcation of burned areas.
- Determination is based on the use of tables:
- E.g. rule of nine and Lund and Browder chart Calculation of the percentage of TBSA burned
Serves as a guide for fluid therapy.
Full fluid resuscitation is necessary for partial or full thickness burns of 20% TBSA or greater.

Assessment of Burn Injury
- First Degree
- Second Degree(Partial thickness)
- Third Degree(Full thickness)

First Degree
Pink to red
Slight edema, which subsides quickly.
Pain may last up to 48 hours; relieved by cooling.
Sunburn is a typical example.
First Degree Reparative Process:
o In about 5 days - epidermis peels AND heals spontaneously.
o Itching and pink skin persist for about a week.
o No scarring.
o If burn does not become infected, heals spontaneously within 10-14 days.

Second Degree (Partial thickness)
Superficial:
Pink or red blisters (vesicles) form; weeping, edematous, and elastic.
o Superficial layers of skin are destroyed; wound moist and painful.
o Hair does not pull out easily.
Second Degree(Partial thickness) Superficial: Reparative Process
o Takes several weeks to heal.
o Scarring may occur.
Deep dermal:
Mottled white and red: edematous reddened areas blanch on pressure.
May be yellowish but soft and elastic
May or may not be sensitive to touch
Sensitive to cold air and Hair pulls out easily.
Second Degree(Partial thickness) Deep dermal: Reparative Process
o Takes several weeks to heal.
o Scarring may occur.

Third Degree (Full thickness)
Reddened areas do not blanch with pressure.
Not painful and inelastic
Coloration varies from waxy white to brown; leathery devitalized tissue is called eschar.
Destruction of epithelium, fat, muscles, and bone.
Third Degree(Full thickness): Reparative Process
o Eschar must be removed.
o For areas larger than 1 -2 inches (3-5 cm), grafting is required.
o Expect scarring and loss of skin functions.
o Area requires debridement, formation of granulation tissue, and grafting.

HEMODYNAMIC STABILIZATION: I.V. Fluid Therapy
To give sufficient fluid to allow perfusion of vital organs without overhydrating the patient
o Preventing later complications
o Prevent circulatory overload.
Immediate I.V. fluid resuscitation is indicated for:
Adults involving more than 18% to 20% of TBSA.
Children involving more than 12% to 15% of TBSA.
o A crystalloid (Ringer's lactate) solution is used initially.
o Colloid is used during the second day
E.g. 5% albumin
Plasmanate
Hetastarch
o Several formulas may be used to determine the amount of fluid to be given in the first 48 hours.
The Parkland formula is most commonly used.
The Brooks and Evans formulas may also be used.
Parkland formula:
First 24 hours: 4 mL of Ringer's lactate weight in kg % TBSA burned.
One-half amount of fluid is given in the first 8 hours, calculated from the time of
injury.
If the starting of fluids is delayed, then the same amount of fluid is given over
the remaining time. Remember to deduct any fluids given in the pre-hospital
setting.
o Parkland formula example:
Patient's weight: 70 kg; % TBSA burn: 80%
4 mL 70 kg 80% TBSA = 22,400 mL of Ringer's lactate
First 8 hours: 11,200 mL or 1,400 mL/hour
Second 16 hours: 11,200 mL or 700 mL/hour
Second 24 hours: 0.5 mL colloid weight in kg TBSA +
2,000 mL dextrose 5% in water (D
5
W) Run concurrently over
the 24-hour period.
o Example:
0.5 mL 70 kg 80% = 2,800 mL colloid + 2,000 mL
D
5
W yields 117 mL colloid/hour
84 mL D
5
W per hour
Boluses of crystalloid or colloid may be necessary to keep a
urine output of 0.5 to 1 mL/kg/hour.

METABOLIC SUPPORT
+ Initially, keep the patient on (NPO) status
o Until bowel sounds return (1 to 2 days).
+ However, small amounts (5 to 10 mL/hour) of isotonic enteral tube feedings are typically started within 24
hours
o To help maintain a functioning GI tract.
+ Small amounts of erythromycin may be used: To encourage GI motility.
+ Reduce metabolic stress
o Allaying pain
o Fear
o Anxiety
o Maintaining a warm environment.
+ Nutritional management must be aggressive
o To combat acute nutritional deficiency and weight loss
o Positive nitrogen balance should be the goal throughout the post-burn care.
+ When bowel sounds return: Administer oral fluids and advance diet as tolerated.
o Offer more solid food after 2 to 3 days post-burn
Provide:
3 gm protein/kg body weight
20% of needed calories in form of fats
Remainder in carbohydrates.
Oral anabolic steroids (oxandrolone)
Helps in maintaining lean muscle mass.
o When caloric requirements cannot be met by enteral feedings
Initiate total parenteral nutrition (TPN)
+ Provide potassium and vitamin and mineral supplements (zinc, iron, vitamin C).

WOUND CLEANSING AND DEBRIDEMENT
Treatment of the burn wound includes :
o Daily or twice-daily wound cleansing
o Debridement or hydrotherapy (tubing/showering)
o Dressing changes: Early excision of deep second- and third-degree burns is the goal.
Burn wounds must be cleansed initially by a mild antibacterial cleansing agent and saline solution or water.
o Nonviable tissue (eschar) may be removed through:
Natural
Enzymatic
Mechanical
Surgical debridement
o Burn eschar will begin to separate from the underlying viable tissue by a natural process of
bacterial growth
Which causes a lysis of protein at the viable to nonviable tissue interface?
o Eschar can be removed through daily or twice-daily dressing changes
o Enzymatic agents applied to the burn wound
Used for more rapid debridement of eschar.
o In surgical excision, all nonviable tissue is removed to a viable base or fascia and is then covered
with a biologic dressing e.g. xenograft, allograft

HYDROTHERAPY:
Is bathing of the burn patient in a tub of water or with a water shower to facilitate cleansing and
debridement of the burned area.
Tubing
Tanking
Showering
HYDROTHERAPY: Advantages
Topical medications, adherent dressings, and eschar are more easily removed.
Provides an opportunity for the patient to practice (ROM) exercises.
Total assessment of the burn area is facilitate
Total body cleansing can be achieved.
HYDROTHERAPY: Disadvantages
Loss of body heat and loss of sodium.
Uncomfortable and at times painful for the patient.
Maintenance of I.V. lines and ventilator care may be difficult during bathing and showering.
The patient's anxiety level typically increases
There is usually a fear of drowning
HYDROTHERAPY: Interventions
Describe the procedure to the patient who is experiencing hydrotherapy for the first time.
Select the time for future tubings in collaboration with the patient
Administer a pain-control medication as prescribed
Patient with indwelling catheter
Drain and plug it
Maintain a closed system to avoid contamination.
Aseptic technique is adhered to as closely as possible in preparing the patient for hydrotherapy
Limit hydrotherapy to as brief a time as possible to decrease the loss of body temperature and
subsequent chilling.
Never leave the patient unattended in the tub.
Respect the patient's feelings and expressions of stress, pain, cold, and fatigue.
After treatment, the patient may be weighed before being carefully dressed and returned to the
unit.
Document significant data, including status of the wound.

TOPICAL ANTIMICROBIALS:
Used to cover burn areas
To reduce the number of organisms.
TOPICAL ANTIMICROBIALS: Principles
o They are applied directly to the burn area as ointments, creams, or solution
o They may be incorporated in single-layer dressings that do not stick to the wound but permit
drainage
o When wet dressings are used after a surgical procedure.
They are remoistened every 4 to 6 hours, as ordered.
20-ply gauze will help retain solution at the proper concentration if rewet every 4 hours
Heat loss may be prevented
- Limiting evaporative loss with a dry blanket
- By warming the bed
- Using a heat cradle
- Dry top layer of stockinet or a cotton bath blanket
o Desired characteristics in a topical antimicrobial:
Demonstrates action against a broad spectrum of bacteria.
Has the ability to diffuse through the wound and penetrate the eschar.
Nontoxic and non-injurious to body tissue.
o Previously applied topical cream should be removed and the wound gently cleansed before
applying new cream with each dressing change.
o Extremity dressings should be wrapped distally to proximally
Taking care to avoid circulatory compromise when edema occurs or dressing is too tight.
o Operative excision is very stressful metabolically and incurs heavy blood loss
Therefore, more conservative measures may be indicated for some patients.
o Up to 190 mL of blood may be lost per 1% of burn excised in the adult patient.

BIOLOGIC DRESSINGS
Used to cover large surfaces of the body.
Usually, they are split-thickness grafts harvested either from human cadavers or from other mammalian
donors such as pigs.
Biologic Dressings: Allograft
o Is a graft of skin taken from a person other than the burn victim and applied to a burn wound
temporarily.
o Cadaver is the most common source.
o Other sources may be live donors having a panniculectomy
o Allograft is applied directly (shiny side down) to the denuded area.
Before applying, it may be dipped in saline solution.
It may be trimmed to fit the wound.
Biologic Dressings: xenograft or heterograft
Is a segment of skin taken from an animal such as a pig.
It is useful in preparing debrided area for grafting and is really a biologic dressing.
Donor Criteria
Skin color is unimportant because it is only a temporary graft.
Criteria:
An adult
Free from infection
All donated skin must be tested and free from contagious diseases
Purpose and Benefits of Dressings
o Decreases heat, fluid, and protein losses.
o Reduces bacterial proliferation.
o Closes wound temporarily
o Enhances production and protection of granulation tissue.
o Protects exposed neurovascular and muscle tissue as well as tendons.
o Acts as a test graft to determine when granulating wounds will accept autograft successfully.
o Provides an effective donor-site dressing.
o Biosynthetic Dressings
o Help prevent bacterial contamination.
o Used when permanent autograft is unavailable
When partial-thickness wounds will heal spontaneously over time
NURSING MANAGEMENT OF BURN PATIENTS:
Assessment
Obtain a thorough history, including:
Causative agent
o E.g. hot water, chemical burn
Duration of exposure
Circumstances of injury
o E.g. closed or open space, accidental or intentional
Age
o Obtain a thorough history, including:
Initial treatment
E.g. first aid and pre-hospital emergency care
Pre-existing medical problems
Current medications
o Obtain a thorough history, including:
Concomitant injuries
E.g. From falls, explosions, assaults
Evidence of inhalation injury.
Allergies
Tetanus immunization status.
Height and weight.

Nursing Diagnoses
Impaired Gas Exchange related to inhalation injury
Ineffective Breathing Pattern related to circumferential chest burn, upper airway obstruction, or ARDS
Decreased Cardiac Output related to fluid shifts and hypovolemic shock
Ineffective Tissue Perfusion: Peripheral related to edema and circumferential burns
Risk for Excess Fluid Volume related to fluid resuscitation and subsequent mobilization 3 to 5 days post-
burn

Nursing Management of Burn Patients!!~
Adequate Oxygenation and Respiratory Function
^ Provide humidified 100% oxygen until carbon monoxide level is known.
o Get the initial ABG on room air.
o Assess for signs of hypoxemia (E.g. anxiousness, tachypnea, tachycardia)
o Suspect respiratory injury if burn occurred in an enclosed space.
^ Observe for and report the ff:
o Erythema
o Blistering of buccal mucosa
o Singed nasal hairs
o Burns of lips, face, or neck
o Increasing hoarseness.
^ Monitor respiratory rate, depth, rhythm, and cough.
^ Auscultate breath sounds.
^ Note character and amount of respiratory secretions.
o Report carbonaceous sputum and tracheal tissue.
^ Observe for signs of inadequate ventilation
o Begin serial monitoring of ABG levels and oxygen saturation.
^ Keep intubation equipment nearby
^ Be alert for signs of respiratory obstruction.
^ In mild inhalation injury:
o Provide humidification of inspired air.
o Encourage coughing and deep breathing.
^ In moderate to severe inhalation injury:
o Initiate more frequent bronchial suctioning.
o Closely monitor vital signs, urine output, and ABG levels.
o Administer bronchodilator treatments as ordered.

Maintaining Tidal Volume and Unrestricted Chest Movement
C Observe rate and quality of breathing
C Assess tidal volume
o Report decreasing volume
o Encourage deep breathing and incentive spirometry
C Place in semi-Fowler's position
o To permit maximal chest excursions if there are no contraindications
o Not too tight dressings.
C Prepare the patient for escharotomy

Supporting Cardiac Output
O Position the patient: That will increase venous return.
O Give fluids
O Monitor vital signs.
O Determine cardiac output
O Monitor sensorium.
O Document all observations Particularly note trends in vital sign changes.

Promoting Peripheral Circulation
g Remove all jewelry and clothing
g Elevate extremities
g Monitor peripheral pulses hourly.
g Prepare the patient for escharotomy: If circulation is impaired.

Facilitating Fluid Balance
Titrate fluid intake as tolerated
o The initial resuscitation formula is only a base.
o Maintain accurate intake and output records.
o Weigh the patient daily.
o Monitor results of serum potassium and other electrolytes.
o Be alert to signs of fluid overload and heart failure
During initial fluid resuscitation
o Administer diuretics
o Cleanse wounds and change dressings twice daily.
o Perform debridement of dead tissue
Limit time to 20 to 30 minutes depending on the patient's tolerance.
o Apply topical bacteriostatic agents
Applied 1/8-inch (3-mm) thick.
o Dress wounds as appropriate
o For grafted areas, use extreme caution in removing dressings
Report serous or sanguineous blebs or purulent drainage.
o Promote healing of donor sites by:
Opening to air for drying postoperatively if gauze
If exudate occurs after the first 24 hours
A. Swab the area for culture
B. Applies an antimicrobial topical cream.
o Culture is positive; treatment will be in accord with sensitivities.
Allowing dressing to peel off spontaneously.
Cleansing healing donor site with mild soap and water when dressings are removed
Lubricating site twice daily and as needed.

Preventing Urinary Infection
Maintain closed urinary drainage system and ensure patency.
Frequently observe color, clarity, and amount of urine.
Empty drainage bag frequently.
Provide catheter care
o Washing with soap and water.
Encourage removal of catheter and use of urinal
o When frequent urine output determinations are not required.

Stable Body Temperature
O Do not expose wounds unnecessarily.
O Maintain warm ambient temperatures.
O Use warming blankets To keep the patient warm.
O Administer antipyretics
O Obtain urine, sputum, and blood cultures for temp above (38.9 C)
o Rectal or core temperature
o If chills are present.
O Provide a dry top layer for wet dressings
O To reduce evaporative heat loss.
O Warm wound cleansing and dressing solutions to body temperature.

Avoiding Wound and Systemic Infection
= Wash hands always
= Use isolation gown or plastic apron requiring contact with the patient or the patient's bed.
= Be alert for reservoirs of infection
= Cover hair and wear mask
o When wounds are exposed or when performing a sterile procedure.
= Use sterile examination gloves
o for all dressing changes and all care involving patient contact.
= Check history of tetanus immunization
= Change I.V. tubing and lines
= Administer antibiotics
= Assess wounds daily for local signs of infection
= Be alert for early signs of septicaemia
= Inspect skin carefully:
o For signs of pressure and breakdown.
o Observe signs of thrombophlebitis or catheter-induced infections.
= Prevent atelectasis and pneumonia
o through chest physical therapy, postural drainage

Promoting Mobility & ADLs
O Collaborate with physical and occupational therapist
o Exercise the patient at least once or twice daily.
O Encourage the patient to be as active and to perform active ROM exercises
O Maintain splints in proper
O Avoid flexion of burned joints.
O Initiate breathing exercises during early post-burn period.
O Act as advocate for the patient's need
O Help the patient achieve adequate relaxation and sleep

Adequate Nutrition
Weigh the patient daily with dressings removed.
Obtain consultation from dietitian for calculation of nutritional needs

Preventing Paralytic Ileus and Stress Ulcer
; Assess bowel sounds every 2 to 4 hours while acutely ill.
o Decreased peristalsis may be an early sign of septicaemia.
; Small amounts of tube feedings, 5 to 10 mL/hour, immediately following the initial injury
o To help prevent paralytic ileus or stress ulcer.
; Check amount and pH of gastric drainage or aspirate
; Administer histamine-2 blockers and antacids
o This will help prevent or diminish the occurrence of stress (Curling's) ulcers.
; Provide mouth care every 4 hours while intubated.
; Test stools for occult bleeding.

Reducing Pain
Offer analgesics before wound care
o Analgesia given orally before is given 30 to 45 minutes before the procedure.
o E.g. Ketamine I.V.
Supporting extremities with pillows of burned area.
Reduce anxiety thru explanations of procedures.
Teach relaxation techniques

Enhancing Coping
Assure the patient of the normality of responses and the effect that time and healing will likely have on
current concerns.
Support family and friends' communications
o Ask the family members to visit the patient.
Assess need for mental health consultation.
Offer anti-anxiety medications as prescribed.
encourage the patient to express concerns regarding changes in self-image
Be honest, but positive, in responding to the patient and family.

Positive Body Image
Arrange for the patient to see face (if burned) with appropriate supportive personnel
o Do the intervention before being placed/ transferred to a room with access to a mirror.
Arrange for the patient to talk with other patients who have had a similar injury and are progressing
satisfactorily.
Encourage participation in a burn survivor's group
Use and emphasize the concept of being a burn survivor.
o REMEMBER: Survivors needs to continue LIFE.
Avoid the use of the term burn victim
o Because it enhances the sick role.
Refer to psychological services as needed.
Patient Education and Health Maintenance

Health education is closely related to rehabilitation as the burn patient prepares to
return to a productive place in society.
Patient Education and Health Maintenance
1. Assist the patient in transition from dependence on the health team to independence
2. Guide the patient in thinking positively about self.
3. Promote ability to redirect others' attention from the scarred body to the self within.
4. Instruct the patient in measures to lubricate and enhance comfort of healing skin:
5. After cleaning, use moisturizers
6. Wear clean white underwear and clothing free from irritating dyes until wounds are well healed.
7. Take antipruritic as prescribed.
8. Instruct the patient in measures to lubricate and enhance comfort of healing skin:
9. Stay in a cool environment if itching occurs.
10. Protect skin from further trauma
11. Use a sunscreen SPF of 24 or higher. Instruct the patient in measures to lubricate and enhance
comfort of healing skin:
Discuss summer precautions
Include a hat with a full, wide brim if there were facial or neck burns.
Limit exposure to sun, because the affected areas will sunburn more easily and
tan more deeply.
12. Instruct the patient in measures to lubricate and enhance comfort of healing skin:
Advise the patient that if wearing a pressure vest with or without sleeves, or tights, the
patient should also be aware of the need for oral fluid replacement.
13. Review with the patient and family common emotional responses
Image adjustment disorders or posttraumatic stress issues. If not already in place,
psychological referral is appropriate as an outpatient.
Make sure that the patient has a phone number or referral to the counsellor should he or
she want to make follow-up appointments.
Make sure that information has been given about follow-up evaluations and home health
care services, as needed, in the interim.