STUDY GUIDE EXAM 5

Understand the concept of triage in Emergency nursing

Triage system: categorizes patients so most critical are treated first

Emergency Severity Index:
Five-level triage system that incorporates illness severity and resource
utilization
The ESI includes a triage algorithm that directs you to assign an ESI level
to patients presenting to the ED.

Be familiar with the ESI triage system.

Color coding system, and priority/emergent, etc. classifications. Know clinical examples of
each of these.

Color, words or numbers sorting system

Colors: Red/emergent, yellow/urgent, Green/non-urgent

Numbers: Priority I/emergent, priority II/urgent, Priority III/non-urgent

Emergent
Life/limb, or eye threatening; needs immediate attention
Trauma, chest pain, cardiac arrest, severe respiratory distress, chemicals in the eyes, limb
amputation, acute neurological deficits
Urgent
Needs treatment in 20 minutes to 2 hours
Fever > 104 F, diastolic BP > 130 mm Hg, kidney stone, simple fracture, abdominal pain, and
asthma/no respiratory distress
Non-urgent
Can wait hours or days
Sprain, minor laceration, cold symptoms, rash, simple HA

What is primary and secondary survey?

Emergency Nursing

Primary survey focuses on airway, breathing, circulation, and disability,

exposure (ABCDE)
Identifies life-threatening conditions
If life-threatening conditions related to ABCD are identified during primary survey, interventions
are started immediately and before proceeding to the next step of the survey!
Primary Survey
Airway with cervical spine stabilization and/or immobilization Nearly all immediate trauma deaths occur because of airway obstruction.

Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures,
and the tongue can obstruct the airway.
Patients at risk for airway compromise include those who have seizures, near-drowning,
anaphylaxis, foreign body obstruction, or cardiopulmonary arrest.
Signs/symptoms in patient with compromised airway
Dyspnea
Inability to vocalize
Presence of foreign body in airway
Trauma to face or neck
Maintain airway: least to most invasive method
Open airway using the jaw-thrust maneuver.
Suction and/or remove foreign body.
Insert nasopharyngeal/oropharyngeal airway.
Provide endotracheal intubation.
Rapid-sequence intubation
Preferred procedure for unprotected airway
Involves sedation or anesthesia and paralysis
If unable to intubate because of airway obstruction, an emergency cricothyroidotomy or
tracheotomy is performed.
Primary Survey
Breathing
Assess for dyspnea, cyanosis paradoxical/asymmetric chest wall movement, decreased/absent
breath sounds, tachycardia, and hypotension
Life-threatening conditions, including fractured ribs, pneumothorax, penetrating injury,
allergic reactions, pulmonary emboli, and asthma attacks, can cause breathing alterations.
Interventions - Breathing
Administer high-flow O2 via a non-rebreather mask.
Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions
Monitor patient response.
Circulation - If a pulse is felt, assess the quality and rate. Assess the skin for color, temperature,
and moisture. Altered mental status and delayed capillary refill (longer than 3 seconds) are the
most significant signs of shock. Take care when evaluating capillary refill in cold environments
because cold delays refill.
Apply direct pressure to any obvious bleeding sites with a sterile dressing.
Obtain blood samples for typing to determine ABO and Rh group.
Check central pulse (peripheral pulses may be absent because of injury or
vasoconstriction).
Interventions - Circulation
Insert two large-bore IV catheters.

Insert intravenous (IV) lines into veins in the upper extremities unless
contraindicated, such as in a massive fracture or an injury that affects limb
circulation.
Initiate aggressive fluid resuscitation using normal saline or lactated Ringers solution.
Disability: measured by patients level of consciousness
AVPU
A = alert
V = responsive to voice
P = responsive to pain
U = unresponsive
Glasgow Coma Scale
Pupils
Exposure/environmental control - Once the patient is exposed, it is important to limit heat loss,
prevent hypothermia, and maintain privacy by using warming blankets, overhead warmers, and
warmed IV fluids.
Remove clothing to perform physical assessment.
Prevent heat loss.
At this point, determine whether to proceed with the secondary survey or perform additional
interventions.

Secondary Survey Full set of vital signs/Five interventions/Facilitate family

presence
Complete set of vital signs
Blood pressure (bilateral)
Heart rate
Respiratory rate
Oxygen saturation
Temperature
Secondary Survey
Five interventions -These focused adjuncts are considered for patients who sustain significant
trauma and/or require lifesaving interventions during the primary survey.
Initiate ECG monitoring.
Initiate pulse oximetry.
Insert indwelling catheter.
Insert orogastric/nasogastric tube.
Collect blood for laboratory studies.

Facilitate family presence Patients report that having caregivers present comforts them;
caregivers serve as advocates for them and help to remind the health care team of their
personhood.
Family presence: family members who wish to be present during invasive
procedures/resuscitation view themselves as participants in care
Their presence should be supported.
Give comfort measures. General comfort measures such as verbal reassurance, listening,
reducing stimuli (e.g., dimming lights), and developing a trusting relationship with the patient
and caregiver should be provided to all patients in the ED.
Pain management strategies combination of
Pharmacologic measures
Nonpharmacologic measures
History and head-to-toe assessment:
Obtain history of event, illness, injury from patient, family, and emergency personnel.
Perform head-to-toe assessment to obtain information about all other body systems.
Details of the incident are extremely important because the mechanism of injury and
injury patterns can predict specific injuries. For example, a restrained front-seat
passenger may have a head injury or knee, femur, or hip fracture from hitting the
dashboard, and an abdominal injury caused by the seat belt.
The history should include the following questions:
1. What is the chief complaint? What caused the patient to seek attention?
2. What are the patients subjective complaints?
3. What is the patients description of pain (e.g., location, duration, quality, character)?
4. What are witnesses (if any) descriptions of the patients behavior since the onset?
5. What is the patients health history? The mnemonic AMPLE is a memory aid that prompts
you to ask about the following:
A: Allergies to drugs, food, environment
M: Medication history
P: Past health history (e.g., preexisting medical and/or psychiatric conditions, previous
hospitalizations/surgeries, smoking history, recent use of drugs/alcohol, tetanus immunization,
last menstrual period, baseline mental status)
L: Last meal
E: Events/environment leading to the illness or injury
Inspect the posterior surfaces.
Logroll patient (while maintaining cervical spine immobilization) to inspect the posterior
surfaces.
-Inspect the back for ecchymosis, abrasions, puncture wounds, cuts, and obvious
deformities.
-Palpate the entire spine for misalignment, deformity, and pain.

-Evaluate need for tetanus prophylaxis.

Provide ongoing monitoring, and evaluate patients response to interventions.
Prepare to :
Transport for diagnostic tests (e.g., x-ray)
Admit to general unit, telemetry, or intensive care unit
Transfer to another facility
-The nurse may accompany critically ill patients on transports.
-The nurse is responsible for monitoring the patient during transport, notifying the health
care team should the patients condition become unstable, and initiating basic and
advanced life-support measures as needed.

What are the differences between the two surveys? What assessments occur within each survey?
What interventions occur within each survey? Know clinical examples for each survey.
What happens when there has been a death in the ER?
Must recognize importance of hospital rituals in preparing the bereaved to grieve.
These can include collecting the belongings, arranging for an autopsy, viewing the body,
and making mortuary arrangements.
Whenever possible, provide an area for privacy, and, if appropriate, arrange for a visit
from a chaplain.
Determine if patient could be candidate for nonheart beating donation.
Tissues and organs (e.g., corneas, heart valves, skin, bone, and kidneys) can be harvested from
patient after death.
Approaching caregivers about donation after an unexpected death is distressing to both
the staff and the caregivers. For many, however, the act of donation may be the first
positive step in the grieving process.
Organ procurement organizations (OPOs) are available to assist in the process of
screening potential donors, counseling donor families, obtaining informed consent, and
harvesting organs from patients who are on life support or who die in the ED.
What are the gerontologic considerations in the Emergency Department?

Elderly are at high risk for injuryprimarily from falls.

Important to determine whether physical findings may have caused fall or may be due to
fall
Of the injury-related admissions for people 65 years old, most involve fractures,
with many of these resulting from falls.

 The three most common causes of falls in the elderly are generalized weakness,
environmental hazards (e.g., loose mats, furniture), and orthostatic hypotension
(e.g., side effect of medications, dehydration).

Causes
Generalized weakness
Environmental hazards
Orthostatic hypotension

What is heat exhaustion?

Prolonged exposure to heat over hours or days

This occurs when thermoregulatory mechanisms such as sweating, vasodilation, and
increased respirations cannot compensate for exposure to increased ambient
temperatures.
Strenuous activities in hot or humid environments, clothing that interferes with
perspiration, high fevers, and preexisting illnesses predispose individuals to heat stress.
Leads to heat exhaustion

What are the clinical manifestations of heat exhaustion?

Fatigue
Light-headedness
Nausea/vomiting
Diarrhea
Feelings of impending doom
Tachypnea
Tachycardia
Dilated pupils
Mild confusion
Ashen color
Profuse diaphoresis
Hypotension and mild to severe temperature elevation (99.6 to 104 F [37.5 to
40 C]) due to dehydration
Heat exhaustion usually occurs in individuals engaged in strenuous activity in hot, humid
weather, but it also occurs in sedentary individuals.
What are the treatments for heat exhaustion?

Place patient in cool area and remove constrictive clothing.

Place moist sheet over patient to decrease core temperature.

Provide oral fluid.
Replace electrolytes.
Initiate normal saline IV solution if oral solutions are not tolerated.

Monitor the patient for ABCs, including cardiac dysrhythmias (due to electrolyte
imbalances).
Salt tablets are not used because of potential gastric irritation and hypernatremia.
Consider hospital admission for the elderly, the chronically ill, and those who do not
improve within 3 to 4 hours.

What are the differences between heat stroke and heat exhaustion?

What are the special considerations concerning the elderly and heat related issues?

Elderly have decreased ability to perspire, less subQ tissue, as well as decreased ability
to vasodilate, decreased thirst mechanism, diminished ability to concentrate urine, may
not drink enough water
Tend to keep windows closed

What is heat stroke?

Heatstroke is the most serious form of heat stress.

The patient has core temperature greater than 104 F (40 C), altered mentation,
absence of perspiration, and circulatory collapse. The skin is hot, dry, and ashen.
Cerebral edema and hemorrhage may occur as a result of direct thermal injury to the
brain and decreased cerebral blood flow.
Failure of the hypothalamic thermoregulatory processes
Vasodilation, increased sweating, and respiratory rate deplete fluids and electrolytes,
specifically sodium.
Sweat glands stop functioning, and core temperature increases (>104 F [40 C]).

What are the clinical manifestations of heat stroke?

PATIENT IS WARM AND DRY WITH A TEMP >104.0 OR 40.0
What are the treatments for heat stroke?

Treatment: stabilize patients ABCs and rapidly reduce temperature

Cooling methods
Remove clothing.
Cover with wet sheets.
Place patient in front of large fan.
Immerse in ice water bath.
Administer cool fluids or lavage with cool fluids.

Administration of 100% O2 compensates for the patients hypermetabolic state. Ventilation with
a BVM or intubation and mechanical ventilation may be required.

Shivering: increases core temperature, complicates cooling efforts

Aggressive temperature reduction until core temperature reaches 102 F (38.9 C)
Monitor for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular
coagulation. The muscle breakdown leads to myoglobinuria, which places the kidneys at
risk for acute failure.

What is hypothermia? What are the clinical manifestations?

Hypothermia
Core temperature <95 F (<35 C)
Risk factors
Elderly
Certain drugs
Alcohol
Diabetes
Core temperature <86 F (30 C) is potentially life-threatening.

Wet clothing increases evaporative heat loss to 5 times greater than normal; immersion
in cold water (e.g., near drowning) increases evaporative heat loss to 25 times greater
than normal.
Hypothermia mimics cerebral or metabolic disturbances causing ataxia, confusion, and
withdrawal, so the patient may be misdiagnosed.

Know the difference between mild, moderate and sever hypothermia.

Mild hypothermia (93.2 to 96.8 F

[34 to 36 C])
Shivering
Lethargy
Confusion
Rational to irrational behavior
Minor heart rate changes

Moderate hypothermia (86 to 93.2 F [30 to 34 C])

Rigidity
Bradycardia, bradypnea
Blood pressure by Doppler
Metabolic and respiratory acidosis
Hypovolemia
Shivering disappears at temperature
86 F (30 C).

Severe hypothermia (<86 F [30 C]) makes the person appear dead.
Bradycardia
Asystole
Ventricular fibrillation

Metabolic rate, heart rate, and respirations are so slow that they may be difficult to detect.
Reflexes are absent and pupils fixed and dilated
Know treatment differences for each.

Warm patient to at least 90 F (32.2 C) before pronouncing dead.

Cause of deathrefractory ventricular fibrillation
Treatment of hypothermia
Manage and maintain ABCs.

 Rewarm patient.
Correct dehydration and acidosis.
Treat cardiac dysrhythmias.

Mild hypothermia: passive or active external rewarming

Passive external rewarming: Move patient to warm, dry place; remove damp
clothing; place warm blankets on patient.
Active external rewarming:
body-to-body contact, fluid- or
air-filled warming blankets, radiant heat lamps

Gentle handling is essential to prevent stimulation of the cold myocardium.

Closely monitor the patient for marked vasodilation and hypotension during rewarming.

Moderate to severe hypothermia: active core rewarming

Use of heated, humidified oxygen
Warmed IV fluids
Peritoneal, gastric, or colonic lavage with warmed fluids

Consider cardiopulmonary bypass or continuous arteriovenous rewarming in severe

hypothermia.

Know implications involved in rewarming.

Risks of rewarming
Afterdrop, a further drop in core temperature
Hypotension
Dysrhythmias
Rewarming should be discontinued
once the core temperature reaches 95 F (35 C).

What is submersion injury?

Drowning: death from suffocation after submersion in fluid

Immersion syndrome occurs with immersion in cold water, which leads to
stimulation of the vagus nerve and potentially fatal dysrhythmias.
Near-drowning: survival from potential drowning

What are the differences between actual drowning, immersion syndrome and neardrowning? How does treatment differ for these?
Near drowning
Delayed pulmonary edema
All victims of near drowning should be observed for 4-6 hours
Submersion Injury
Initial evaluation: ABCD
Mechanical ventilation with PEEP or CPAP to improve gas exchange when
pulmonary edema is present
Ventilation and oxygenation are the primary techniques for treating respiratory failure.
Mannitol (Osmitrol) or furosemide (Lasix) is used to decrease free water and treat cerebral
edema.
Deterioration in neurologic status: cerebral edema, worsening hypoxia, profound
acidosis
Observe for minimum of 4 to 6 hours.
Secondary drowning is a concern with patients who are essentially symptom-free.

Near-drowning victims may also have head and neck injuries that cause prolonged alterations in
level of consciousness.

Complications can develop in patients who are essentially free of symptoms immediately after
the near-drowning episode. This secondary drowning refers to delayed death from drowning due
to pulmonary complications.
Know and understand tick bites, tick paralysis, and treatment. Know and understand bee
stings, medical emergency associated with bee stings and treatment.
What is the difference between human and animal bites? What complications are seen with
each? Which age group is most susceptible to each type of bite? What treatments would be
given for bites?
Animal Bites
Children at greatest risk
Animal bites from dogs and cats are most common, followed by bites from wild or
domestic rodents.
Complications
Infection
Mechanical destruction of skin, muscle, tendons, blood vessels, bone
Every year, more than 5 million animal bites are reported in the United States.
The bite may cause a simple laceration or may be associated with crush injury, puncture wound,
or tearing of multiple layers of tissue.

Initial treatment: clean with copious irrigation, debridement, tetanus prophylaxis, and
analgesics
Prophylactic antibiotics for bites at risk for infection
Wounds over joints
Wounds less than 6 to 12 hours old
Puncture wounds
Bites on hand or foot
Individuals at greatest risk of infection are infants, older adults, immunosuppressed patients,
alcoholics, diabetic individuals, and those taking corticosteroids.

Animal and Human Bites

Puncture wounds left open
Lacerations loosely sutured
Wounds over joints splinted

The patient is admitted for IV antibiotic therapy when an infection is present.

Incidence of cellulitis, osteomyelitis, and septic arthritis is increased in these patients.
Report animal and human bites to the police as required.

Rabies prophylaxis essential in management of animal bites

Initial injection: rabies immune globulin
Series of five injections of human diploid cell vaccine: days 0, 3, 7, 14, and 28

What types of poisonings are seen in the ER? What is the treatment for these persons? How
does the treatment differ depending on the severity of the poisoning? How can decreased
absorption occur? What methods and agents are used to help decreased absorption within
the body?

Chemicals that harm the body accidentally, occupationally, recreationally, or intentionally

Severity depends on type, concentration, and route of exposure.

More than 5 million cases of human poisonings occur each year in the United States.
Poisonings can be accidental, occupational, recreational, or intentional.
Natural or manufactured toxins can be ingested, inhaled, injected, splashed in the eye, or
absorbed through the skin.
Table 69-11 presents common poisons.

Poisonings
Management
Decrease absorption (lavage, charcoal).
Enhance elimination.
Implement toxin-specific interventions per poison control center (antidotes).

Options for decreasing absorption of poisons include activated charcoal, dermal cleansing, eye
irrigation, and, less frequently, gastric lavage.
Administration of cathartics, whole-bowel irrigation, hemodialysis, urine alkalization, chelating
agents, and antidotes promote the elimination of poisons.
Poisonings
Management
Decrease absorption (lavage, charcoal).
Enhance elimination.
Implement toxin-specific interventions per poison control center (antidotes).
Options for decreasing absorption of poisons include activated charcoal, dermal cleansing, eye
irrigation, and, less frequently, gastric lavage.

Administration of cathartics, whole-bowel irrigation, hemodialysis, urine alkalinization,

chelating agents, and antidotes promote the elimination of poisons.
Poisonings
Decreasing absorption
Gastric lavage
Intubate before lavage if altered level of consciousness or diminished gag
reflex
Perform lavage within 2 hours of ingestion of most poisons.
Contraindicated
Caustic agents
Co-ingested sharp objects
Ingested nontoxic substances
Poisonings
Activated charcoal
Most effective intervention: administer orally or via gastric tube within 60
minutes of poison ingestion
Contraindications
Diminished bowel sounds
Paralytic ileus
Ingestion of substance poorly absorbed by charcoal
Charcoal can absorb and neutralize antidotes: do not give immediately
before, with, or shortly after charcoal
Poisonings
Decontamination takes priority over all interventions except basic life support
measures.
Poisonings
Hemodialysis/hemoperfusion
Reserved for severe acidosis
Urine alkalinization
Chelating agents
Antidotes
Hemodialysis is reserved for patients who develop severe acidosis from ingestion of toxic
substances (e.g., aspirin).
Sodium bicarbonate administration raises the pH (>7.5), which is particularly effective for
phenobarbital and salicylate poisoning.
Vitamin C is added to IV fluids to enhance excretion of amphetamines and quinidine.
Chelation therapy is considered for heavy metal poisoning (e.g., edetate calcium disodium
[Calcium EDTA] for lead poisoning).

Poisonings
Enhance elimination.
Cathartics (e.g., sorbitol)
Give with first dose of charcoal to stimulate intestinal motility/increase
elimination.
Whole-bowel irrigation
Whole-bowel irrigation can be effective for swallowed objects such as cocaine-filled balloons or
condoms, and heavy metals such as lead and mercury.

How do the ER personnel address the patient who has attempted suicide?

Must be evaluated by mental health provider

Screening tool exists to identify those at risk for suicide and/or repeat attempts

How do the ER personnel address violence that occurs within families and domestic
situations?
Violence
Acting out of emotions (e.g., fear or anger) to cause harm to someone or something
Organic disease
Psychosis
Antisocial behavior
The patient cared for in the ED may be the victim of violence or the perpetrator of violence.
Violence can take place in a variety of settings, including the home, community, and workplace.
EDs have been identified as high-risk areas for workplace violence.

Family and Intimate Partner Violence

Pattern of coercive behavior in a relationship; involves fear, humiliation, intimidation,
neglect, and/or intentional physical, emotional, financial, or sexual injury

The ENA encourages ED nurses to become certified sexual assault nurse examiners (SANE). The
SANE nurse provides expert emergency care, collects and documents evidence, participates in
staff and community education, and advocates for sexual assault and rape victims.
Screening for domestic violence is required in ED.
Barriers to conducting effective screening include limited privacy for screening, lack of time,
and lack of knowledge about how to obtain information regarding family and IPV.
Appropriate interventions

Make referrals.
Provide emotional support.
Inform victims about options.

Domestic Violence
Intimate partner violence including sexual assault
*Nurse stays with client
*Written consent to collect evidence including photos
*Police report patient decision
*Children and vulnerable adults exception (mandatory reporting)
How is the sexual assault victim helped in the ER?

Crisis intervention begins immediately

Patient is seen immediately
Collection of forensic evidence
Specially trained nurses; sexual assault nurse examiner (SANE)

Patients reaction to rape; rape trauma syndrome

What is terrorism? How do the ER personnel address persons affected by terrorism? What
are the most commonly expected agents that would be used in a terrorist attack and how
will the ER personnel prepare and treat persons in these situations?
Terrorism - Table 69-12
Involves overt actions for the expressed purpose of causing harm
Disease pathogens (e.g., bioterrorism)
Chemical agents
Radiologic/nuclear, explosive devices
Bioterrorism
Anthrax, plague, and tularemia: treated with antibiotics, assuming sufficient supplies and
nonresistant organisms
Smallpox can be prevented or ameliorated by vaccination even when first given after
exposure.
Agents most likely to be used in a terrorist attack are anthrax, smallpox, botulism, plague,
tularemia, and hemorrhagic fever.
Botulism is treated with antitoxin.
No treatment has been established for most viruses that cause hemorrhagic fever.

Chemical Agents of Terrorism Table 69-13

Categorized by target organ or effect
Sarin: toxic nerve gas that can cause death within minutes of exposure
Enters body through eyes and skin
Acts by paralyzing respiratory muscles
Antidotes for nerve agents: atropine, pralidoxime chloride
Phosgene: colorless gas normally used in chemical manufacturing
If inhaled at high concentrations for long enough period, causes severe
respiratory distress, pulmonary edema, and death
Mustard gas: yellow to brown in color with garlic-like odor
Irritates eyes and causes skin burns/blisters
Protocols to treat victims of chemical exposure vary according to the specific agent.

Radiologic/Nuclear Agents of Terrorism

Radiologic dispersal devices (RRDs) (dirty bombs): mix of explosives and radioactive
material
When detonated, blast scatters radioactive dust, smoke, and other material into
environment, resulting in radioactive contamination.
Main danger from RRDs: explosion
Ionizing radiation (e.g., nuclear bomb, damage to a nuclear reactor): serious threat to
safety of casualties and environment
Exposure may or may not include skin contamination with radioactive material.
Radioactive materials used in an RRD (e.g., uranium, iodine-131) do not usually generate
enough radiation to cause immediate serious illness, except for those victims who are in close
proximity to the explosion.
Initiate decontamination procedures immediately if external radioactive contaminants are
present.
Acute radiation syndrome develops after substantial exposure to ionizing radiation and follows a
predictable pattern.

Explosive Devices as Agents of Terrorism

Result in one or more of following types of injuries: blast, crush, or penetrating
Blast injuries from supersonic over pressurization shock wave that results from
explosion
Damage to the lungs, middle ear, gastrointestinal tract
Crush injuries (i.e., blunt trauma) often result from explosions that occur in confined spaces as
the result of structural collapse (e.g., falling debris).
Some explosive devices contain materials that are projected during the explosion (e.g.,
shrapnel), leading to penetrating injuries.

What is a mass casualty incident?

Manmade or natural event or disaster that overwhelms communitys ability to respond

with existing resources

MCIs usually involve large numbers of victims, physical and emotional suffering, and permanent
changes within a community.
In addition, MCIs always require assistance from people and resources outside the affected
community (e.g., American Red Cross, Federal Emergency Management Agency [FEMA]).
What is the difference between the military and the civilian model and how does this
impact treatment during a mass casualty?
Military model
Those with the least serious wounds may be the first treatment priority
Civilian model (Mass casualty, disaster)
Those with the most serious but realistically salvageable injuries are treated first
In both models, victims with clearly lethal injuries or those who are unlikely to survive even with
extensive resource application are treated as the lowest priority.
What triage system is used during this situation?
Why triage in a crisis/disaster?
Way to find organization in the in the midst of chaos
Helps to get care to those who need it and will benefit from it the most
Helps in resource allocation
Provides an objective framework for stressful and emotional decisions
Emergency and Mass Casualty Incident Preparedness
When an emergency or MCI occurs, first responders (e.g., police, emergency
medical personnel) are dispatched.
Triage of casualties differs from usual ED triage and is conducted in <15 seconds.
System of colored tags designates both seriousness of injury and likelihood of
survival.
Green (minor injury) or yellow
(nonlife-threatening injury) tag indicates noncritical injury.
Red tag indicates life-threatening injury.
Blue tag indicates those who are expected to die.
Black tag identifies the dead.
This slide is one example of a system used in MCI.

Triage of victims of an emergency or MCI must be rapid and conducted in less than 15 seconds.
In general, two thirds of victims will be tagged green or yellow, and the remaining will be tagged
red, blue, or black.
Green
Minor injuries that can wait for longer periods of time for treatment
Minor lacerations, contusions, sprains, superficial burns, partial-thickness burns of < 20% BSA
Yellow
Potentially serious injuries, but are stable enough to wait a short time for medical treatment
Open thoracic wound, penetrating abdominal wound, severe eye injury, avascular limb, fractures,
significant burns other than face, neck or perineum
RED
Life-threatening but treatable injuries requiring rapid medical attention
Airway obstruction, cardio-respiratory failure, significant external hemorrhage, shock, sucking
chest wound, burns of face or neck
Black
Dead or still with life signs but injuries are incompatible with survival in austere conditions
Head injury with GCS<8, burns >85% BSA, multisystem trauma, signs of impending death

Emergency and Mass Casualty Incident Preparedness

Total number of casualties a hospital can expect is estimated by doubling number of
casualties that arrive in first hour.
Generally, 30% will require admission to hospital, and half of these will need
surgery within 8 hours.
Critical incident stress debriefing

Promote effective coping strategies to avoid PTSD or professional burn out

Group leader encourages group discussion by asking a series of questions designed to
make everyone involved tell his or her own story and explain the personal impact.
Helps place incident in perspective and dispel any feelings of blame or guilt

______________________________________________________________________________
_____
What is a burn?

A burn occurs when there is injury to the tissues of the body caused by heat, chemicals,
electric current, or radiation. The resulting effects are influenced by temperature of the
burning agent, duration of contact time, and type of tissue that is injured.

An estimated 500,000 Americans seek medical care each year for burns.

Approximately 40,000 people are hospitalized, one half of whom require care in
specialized burn centers.

About 4000 Americans die annually as a direct result of their burns.

The highest fatality rates occur in children 4 years of age and younger, and in adults over
the age of 65.

Although burn incidence has decreased over the past few years, burn injuries still occur
too frequently, and most should be viewed as preventable. The focus of burn prevention
programs has shifted from concentrating on individual blame and changing individual
behaviors to include more legislative changes.

The aim of these changes is to make improvements in the environment. Coordinated

national programs include child-resistant lighters, nonflammable childrens clothing, tap
water anti-scald devices, fire-safe cigarettes, stricter building codes, hard-wired smoke
detectors/alarms, and fire sprinklers.

You can advocate for burn risk reduction strategies in the home. You also can educate
workers to reduce burn injuries in the work setting.

Who are most at risk?

High Risk Populations

Young children, older adults, drug or alcohol abusers, chronically ill or debilitated, or
those working high risk jobs

What types of burns are there?

Types of Burn Injury

Thermal burns
Caused by flame, flash, scald, or contact with hot objects
Most common type of burn

Chemical burns
Result from tissue injury and destruction from acids, alkalis, and organic
compounds
Alkali burns are hard to manage because they cause protein hydrolysis and
liquefaction.
Damage continues after alkali is neutralized.
Chemical should be quickly removed from the skin.
Clothing containing the chemical should be removed.
Tissue destruction may continue up to 72 hours after a chemical injury.
In addition to tissue damage, eyes can be injured if they are splashed with
a chemical.
Acids are found in many household cleaners and include hydrochloric,
oxalic, and hydrofluoric acid.
Alkali burns can be more difficult to manage than acid burns because
alkaline substances are not neutralized by tissue fluids as readily as acid
substances. Alkalis adhere to tissue, causing protein hydrolysis and
liquefaction. Alkalis are found in oven and drain cleaners, fertilizers, and
heavy industrial cleansers.
Organic compounds, including phenols and petroleum products, produce
contact burns and systemic toxicity. Phenols are found in chemical
disinfectants, and petroleum products include creosote and gasoline.
Smoke inhalation injury
Result from inhalation of hot air or noxious chemicals
Cause damage to respiratory tract
Major predictor of mortality in burn victims
Need to be treated quickly
Three types
Carbon monoxide poisoning
Inhalation injury above the glottis
Inhalation injury below the glottis

Carbon monoxide (CO) poisoning

CO is produced by the incomplete combustion of burning
materials.
Inhaled CO displaces oxygen.
Hypoxia
Carboxyhemoglobinemia
Death
Smoke and inhalation injuries result from the inhalation of hot air or
noxious chemicals and can cause damage to the tissues of the respiratory
tract. Fortunately, gases are cooled to body temperature before they reach
the lung tissue.
Although damage to the respiratory mucosa can occur, it seldom happens
because the vocal cords and glottis close as a protective mechanism.
Redness and airway swelling (edema) may result when damage occurs.
Because smoke inhalation injuries are a major predictor of mortality in
burn patients, rapid assessment is critical.

Electrical burns
Inhalation injury below the glottis
Injury is related to the length of exposure to smoke or toxic fumes.
Pulmonary edema may not appear until 12 to 24 hours after the burn.
Manifests as acute respiratory distress syndrome

Cold thermal injury

What are the clinical manifestations of each? What prehospital and hospital treatment is
given for each type of burn?
Chemical Burns
Chemical should be quickly removed from the skin.
Clothing containing the chemical should be removed.
Tissue destruction may continue up to 72 hours after a chemical injury.
Smoke Inhalation Injuries
Carbon monoxide (CO) poisoning
Treat with 100% humidified oxygen.
CO poisoning may occur in the absence of burn injury to the skin.
Skin color may be described as cherry red in appearance.
Inhalation injury above the glottis

Thermally produced
Hot air, steam, or smoke
Mucosal burns of oropharynx and larynx
Mechanical obstruction can occur quickly
True medical emergency
Mucosal burns of the oropharynx and larynx are manifested by redness, blistering, and edema.

Inhalation injury above the glottisContinued

Reliable clues to this injury:
Presence of facial burns
Singed nasal hair
Hoarseness, painful swallowing
Darkened oral and nasal membranes
Carbonaceous sputum
History of being burned in enclosed space
Clothing burns around chest and neck
Inhalation injury below the glottis
Injury is related to the length of exposure to smoke or toxic fumes.
Pulmonary edema may not appear until 12 to 24 hours after the burn.
Manifests as acute respiratory distress syndrome
An inhalation injury below the glottis is usually chemically produced.

Electrical Burns
Severity of injury depends on
Amount of voltage
Tissue resistance
Current pathways
Surface area
Duration of the flow
Types of Burn Injury
Electrical Burns
Severity of injury depends on
Amount of voltage
Tissue resistance
Current pathways
Surface area
Duration of the flow
Tissue densities offer various amounts of resistance to electric current. For example, fat
and bone offer the most resistance, whereas nerves and blood vessels offer the least
resistance.

Electrical BurnsContinued
Current that passes through vital organs will produce more life-threatening sequelae
than current that passes through other tissue.
Types of Burn Injury
Electrical Burns
Severity of injury can be difficult to assess, as most damage occurs beneath the skin.
Iceberg effect
Patients are at risk for dysrhythmias, severe metabolic acidosis, and myoglobinuria.

As with inhalation injury, a rapid assessment of the patient with electrical injury must be
performed. Transfer to a burn center is indicated.

The severity of an electrical injury can be difficult to determine as most of the damage
occurs below the skin (known as the iceberg effect).

Determination of electric current contact points and history of the injury may help
determine the probable path of the current and potential areas of injury.

Contact with electric current can cause muscle contractions strong enough to fracture
the long bones and vertebrae. Another reason to suspect long bone or spinal fractures is
a fall resulting from the electrical injury. For this reason, all patients with electrical
burns should be considered at risk for a potential cervical spine injury. Cervical spine
immobilization must be used during transport and subsequent diagnostic testing
completed to rule out any injury.

Electrical injury puts the patient at risk for dysrhythmias or cardiac arrest, severe
metabolic acidosis, and myoglobinuria, which can lead to acute renal tubular necrosis
(ATN).

The electric shock event can cause immediate cardiac standstill or fibrillation. Delayed
cardiac dysrhythmias or arrest may also occur without warning during the first 24 hours
after injury.

Myoglobin from injured muscle tissue and hemoglobin from damaged red blood cells
(RBCs) are released into the circulation whenever massive muscle and blood vessel
damage occurs. The released myoglobin pigments are transported to the kidneys, where
they can mechanically block the renal tubules because of their large size. This process
can result in ATN and eventual acute renal failure if not appropriately treated.

How are burns classified?

Classification of Burn Injury

Severity of injury is determined by
Depth of burn
Extent of burn in percent of TBSA
Location of burn
Patient risk factors
The American Burn Association (ABA) has established referral criteria that
recommend which burn injuries should be treated in burn centers where
specialized facilities and personnel are available to handle this type of trauma.
A majority of patients with minor burn injuries that fall outside of the referral
criteria can be managed in community hospitals by nonburn center personnel on
an outpatient basis.
Goals of care include wound healing, prevention of infection, pain management,
and return to preinjury function.

The skin is divided into three layers: the epidermis, dermis, and subcutaneous tissue (Fig. 25-3).
The epidermis, or nonvascular outer layer of the skin, is approximately as thick as a sheet of
paper. It is composed of many layers of nonliving epithelial cells that provide a protective

barrier to the skin, hold in fluids and electrolytes, help to regulate body temperature, and keep
harmful agents in the external environment from injuring or invading the body.
The dermis, which lies below the epidermis, is approximately 30 to 45 times thicker than the
epidermis. The dermis contains connective tissues with blood vessels and highly specialized
structures consisting of hair follicles, nerve endings, sweat glands, and sebaceous glands. Under
the dermis lies the subcutaneous tissue, which contains major vascular networks, fat, nerves,
and lymphatics.
The subcutaneous tissue acts as a heat insulator for underlying structures, which include the
muscles, tendons, bones, and internal organs.
Depth of BurnContinued

Burns have been defined by degrees (1st, 2nd, 3rd, and 4th).
ABA advocates categorizing the burn according to depth of skin destruction.
Partial-thickness burn
Full-thickness burn
Skin-reproducing (re-epithelializing) cells are located throughout the dermis and along
the shafts of the hair follicles and sebaceous glands. If significant damage to the dermis
occurs (e.g., a full-thickness burn), remaining skin cells are insufficient to regenerate
new skin. A permanent, alternative source of skin then needs to be found.

Depth of BurnContinued
Superficial partial-thickness burn
Involves the epidermis
Deep partial-thickness burn
Involves the dermis
Full-thickness burn
Involves fat, muscle, bone
What calculations are used to ascertain the amount of burned area of the body? What is the
significance of the classifications? How does the classification affect treatment?

Classification of Burn Injury

Extent of Burn
Two commonly used guides for determining the total body surface area
Lund-Browder chart

considered more accurate because the patients age, in proportion to

relative body-area size, is taken into account
Rule of nines
Considered adequate for initial assessment of adult patients and easy to
remember.
The Sage Burn Diagram is a free Internet-based tool that is available for estimating
TBSA burned (www.sagediagram.com).
The extent of a burn is often revised after edema has subsided and a demarcation of the
zones of injury has occurred.

Lund-Browder Chart

Rule of Nines Chart

Burn Classification continued

Major burn
Partial thickness burns greater than 25% TBSA
Full thickness burns greater than 10%
Any burns involving the eyes, ears, face hands, feet, perineum
Electrical injury
Inhalation injury
Clients over age of 60 yrs of age, and children under age of 2 years
Burn complicated with other injuries (e.g. fractures)
Client has cardiac, pulmonary, or other chronic metabolic disorder
Location of Burn
Location of the burn is related to the severity of the injury
Face, neck, chest respiratory obstruction
Hands, feet, joints, eyes self-care
Ears, nose, buttocks, perineum infection
Burns to the face and neck and circumferential burns to the chest/back may inhibit
respiratory function because of mechanical obstruction secondary to edema or leathery,
devitalized tissue formation (eschar). These injuries may also signal the possibility of
inhalation injury and respiratory mucosal damage.

Burns of the hands, feet, joints, and eyes are of concern because they make self-care very
difficult and may jeopardize future function. Burns of the hands and feet are challenging
to manage because of superficial vascular and nerve supply systems and the need to
maintain their function during healing.
Burns to the ears and the nose are susceptible to infection because of poor blood supply
to the cartilage.
Burns to the buttocks or perineum are highly susceptible to infection.

Location of Burn
Circumferential burns of the extremities can cause circulatory compromise.
Patients may also develop compartment syndrome!
Patients may also develop compartment syndrome from direct heat damage to the muscles and
subsequent edema and/or preburn vascular problems. See Chapter 63 for more information.

Patient Risk Factors

Older adults heal more slowly than younger adults.
and usually experiences more difficulty with rehabilitation
Preexisting cardiovascular, respiratory, and renal diseases contribute to poorer prognosis.
Because of the tremendous demands placed on the body by a burn injury.
Diabetes mellitus contributes to poor healing and gangrene.
The patient with diabetes mellitus or peripheral vascular disease is at high risk
for poor healing and gangrene, especially with foot and leg burns.
Physical debilitation renders patient less able to recover.
Alcoholism
Drug abuse
Malnutrition
Concurrent fractures, head injuries, or other trauma also lead to poor prognosis.
What are the phases of burn management?
Prehospital care
Emergent (resuscitative)
Acute (wound healing)
Rehabilitative (restorative)
An overlap in care exists from one phase to another. For example, although the emergent phase
is seen as beginning in the emergency department, care often begins in the prehospital phase,
depending upon the skill level of paramedics at the scene. Planning for rehabilitation begins on
the day of the burn injury or admission to the burn center. Formal rehabilitation begins as soon

as functional assessments can be performed. Wound care is the primary focus of the acute phase,
but it also takes place in both the emergent and rehabilitative phases.
Describe prehospital care for each type of burn.

Prehospital Care
Remove the person from the source of the burn and stop the burning process.
Rescuer must be protected from becoming part of the incident.
The burn patient may have sustained other injuries that take priority over the burn wound. It is
important for individuals involved in the prehospital phase of burn care to adequately
communicate the circumstances of the injury to the hospital-based health care providers. This is
especially important when the injury involves entrapment in a closed space, hazardous
chemicals, electricity, or possible trauma (e.g., fall).

Electrical injuries
Remove patient from contact with source.
Chemical injuries
Brush solid particles off the skin.
Use water lavage.
Chemical burns are best treated by quickly removing solid particles from
the skin. Any clothing containing the chemical must also be removed as
the burning process continues while the chemical is in contact with the
skin.
The affected area should be flushed with copious amounts of water to
irrigate the skin anywhere from 20 minutes to 2 hours post exposure. Tap
water is acceptable for flushing eyes exposed to chemicals.
Tissue destruction may continue for up to 72 hours after a chemical burn.
Prehospital Care
Small thermal burns
Cover with clean, cool, tap water dampened towel.
Cooling of the injured area (if small) within 1 minute helps minimize the depth of
the injury.
Large thermal burns
Airway, breathing, and circulation
Airway: Check for patency, soot around nares/on the tongue, singed nasal
hair, darkened oral or nasal membranes.
Breathing: Check for adequacy of ventilation.
Circulation: Check for presence and regularity of pulses, and elevate the
burned limb(s) above the heart to decrease pain and swelling.

Do not immerse in cool water or pack with ice.

To prevent hypothermia, large burns should be cooled for no longer than
10 minutes.
Remove burned clothing.
Wrap in clean, dry sheet or blanket.
Inhalation injury
Observe for signs of respiratory distress or compromise.
Treat quickly.
They need to be treated quickly and efficiently at the scene if they are to
survive. If CO intoxication is suspected, the patient should be treated with
100% humidified O2. Patients with both body burns and inhalation injury
must be transferred to the nearest burn center.

Describe the emergent phase of burn injury.

Emergent phase is the period of time required to resolve immediate problems resulting
from the injury.
Usually lasts up to 72 hours
Primary concerns are onset of hypovolemic shock and edema.
Phase begins with fluid loss and edema formation and continues until fluid
mobilization and diuresis begin.

Address each system of the body and how it is affected during the emergent phase. What
pathophysiologic changes are occurring and how does it affect treatment?
Pathophysiology

Fluid and electrolyte shifts

Greatest threat is hypovolemic shock, caused by a massive shift of fluids out of
blood vessels as a result of increased capillary permeability.
The net result of the fluid shift is intravascular volume depletion.
Edema
Blood pressure
Pulse
Normal insensible loss: 30 to 50 mL/hr
Severely burned patient: 200 to
400 mL/hr
RBCs are hemolyzed by a circulating factor released at the time of the burn.

Thrombosis
Elevated hematocrit
The circulatory status is also impaired because of hemolysis of RBCs.
The RBCs are hemolyzed by circulating factors (e.g., oxygen free radicals) released at
the time of the burn, as well as by the direct insult of the burn injury.
Thrombosis in the capillaries of burned tissue causes an additional loss of circulating
RBCs.
An elevated hematocrit is commonly caused by hemoconcentration resulting from fluid
loss. After fluid balance has been restored, lowered hematocrit levels are found
secondary to dilution.
Na+ shifts to the interstitial spaces and remains until edema formation ceases.
K+ shift develops because injured cells and hemolyzed RBCs release K+ into
extracellular spaces.
Immunologic changes
Burn injury causes widespread impairment of the immune system.
Skin barrier is destroyed.
Bone marrow is depressed.
Circulating levels of immune globulins are decreased.
WBCs develop defects

Can begin as early as 20 minutes post burn.

What is the Parkland formula and how is it implemented?

4 ml LR /Kg/%TBSA burn = total fluid requirements for first 24 hours
Administer total in first 8 hours
total in 2nd 8 hours
total in 3rd 8 hours
Describe treatment for every area of the body during the emergent phase. Can you
prioritize them?
At the time of major burn injury, capillary permeability is increased. All fluid components of the
blood begin to leak into the interstitium, causing edema and a decreased blood volume. The red
blood cells and white blood cells do not leak. Hematocrit increases, and the blood becomes more
viscous. The combination of decreased blood volume and increased viscosity produces increased
peripheral resistance. Burn shock, a type of hypovolemic shock, rapidly ensues, and if it is not
corrected, death can result.

Conditions that lead to burn shock

Emergent Phase
Complications
Cardiovascular system
Dysrhythmias and hypovolemic shock
Impaired circulation to extremities
Tissue ischemia
Necrosis
Circulation to the extremities can be severely impaired by deep
circumferential burns and subsequent edema formation. These processes
occlude the blood supply by acting like a tourniquet.
If untreated, ischemia, paresthesias, necrosis, and eventually gangrene
can occur. An escharotomy (a scalpel or electrocautery incision through
the full-thickness eschar) is frequently performed following transfer to a
burn center to restore circulation to compromised extremities.
Impaired microcirculation and
viscosity sludging
Initially, blood viscosity is increased with burn injuries because of the
fluid loss that occurs in the emergent period. Microcirculation is impaired

by damage to skin structures that contain small capillary systems. These

two events result in a phenomenon termed sludging. Sludging can be
corrected by adequate fluid replacement.

Respiratory system
Upper respiratory tract injury
Edema formation
Mechanical airway obstruction and asphyxia
Upper airway injury results from direct heat injury or edema
formation.
Upper airway distress may occur with or without smoke
inhalation.
The edema associated with an upper respiratory tract burn injury
can be massive and the onset insidious.
Mechanical obstruction of the airway is not limited to the patient
with flame burns to the upper airway. Swelling that accompanies
scald burns to the face and neck can be lethal, as can pressure
from accumulated edema compressing the airway externally.
Flame burns to the neck and chest may contribute to respiratory
difficulty because the inelastic eschar becomes tight and
constricted as a result of the underlying edema.
Lower airway (inhalation) injury
Direct insult at the alveolar level
Interstitial edema
Patient may not exhibit signs during first 24 hours.
Lower airway (or inhalation) injury refers to a direct insult at the
alveolar level secondary to the inhalation of toxic fumes or smoke.
The result is interstitial edema that prevents diffusion of oxygen
from the alveoli into the circulatory system.
Fiberoptic bronchoscopy and carboxyhemoglobin blood levels can
be used to confirm a suspected inhalation injury.
Another diagnostic indicator may be a history of prolonged
exposure to smoke or fumes.
Sputum that contains carbon may be present.
You must be especially sensitive to signs of impending respiratory
distress such as increased agitation, restlessness, or change in the
rate or character of respirations, as the symptoms may not be
present immediately.
Generally, no correlation exists between the extent of TBSA burn
and the severity of inhalation injury because inhalation injury is a

factor of time exposure plus the type and density of the material
inhaled.
The initial chest x-ray may appear normal on admission, with
changes noted over the next 24 to 48 hours.
Arterial blood gas (ABG) values may be within the normal range
on admission and then may change during hospitalization.

Urinary system
Blood flow to kidneys causes renal ischemia.
Acute tubular necrosis (ATN)
With full-thickness and electrical burns, myoglobin (from muscle cell
breakdown) and hemoglobin (from RBC breakdown) are released into the
bloodstream and occlude renal tubules. Adequate fluid replacement can
counteract myoglobin and hemoglobin obstruction of the tubules.
Emergent Phase
Nursing and Collaborative Management
Airway management
Early endotracheal intubation
Escharotomies of the chest wall
Fiberoptic bronchoscopy
Humidified air and 100% oxygen
Although burn management can be chronologically categorized as
emergent, acute, and rehabilitative, the overall care requirements are not
so easily classified. Depending upon the acuity of the patient, the duration
of time spent in each phase varies greatly, and conditions improve and
worsen unpredictably on an almost daily basis. Care changes accordingly.
Although physiotherapy and occupational therapy are a focus of the acute
and rehabilitative phases, proper positioning and splinting begin at the
time of admission.
From the onset of the burn event until the patient is stabilized, nursing and
collaborative management predominantly consists of airway management,
fluid therapy, and wound care.
Airway management frequently involves early endotracheal (preferably
orotracheal) intubation. Early intubation eliminates the necessity for
emergency tracheostomy after respiratory problems have become
apparent. In general, the patient with major injuries involving burns to the
face and neck requires intubation within 1 to 2 hours after burn injury.
After intubation, the patient is placed on ventilatory assistance, and the
delivered oxygen concentration is determined by assessing ABG values.

Extubation may be indicated when the edema resolves, usually 3 to 6 days

after burn injury, unless severe inhalation injury is involved.
Escharotomies of the chest wall may be needed to relieve respiratory
distress secondary to circumferential, full-thickness burns of the neck and
trunk.
Within 6 to 12 hours after injury in which smoke inhalation is suspected, a
fiber optic bronchoscopy should be performed to assess the lower airway.
Significant findings include the appearance of carbonaceous material,
mucosal edema, vesicles, erythema, hemorrhage, and ulceration.
When intubation is not performed, treatment of inhalation injury includes
administration of 100% humidified O2 as needed. Place the patient in a
high Fowlers position, unless contraindicated (e.g., spinal injury), and
encourage coughing and deep breathing every hour. Reposition the patient
every 1 to 2 hours, and provide chest physiotherapy and suctioning as
necessary. If respiratory failure develops, intubation and mechanical
ventilation are initiated.

Fluid therapy
Two large-bore IV lines for >15% TBSA
Type of fluid replacement based on size/depth of burn, age, and individual
considerations
Parkland (Baxter) formula for fluid replacement
Colloidal solutions
Establishing intravenous (IV) access is critical for fluid resuscitation and
drug administration. At least two large-bore IV access routes must be
obtained for burns >15% TBSA. It is critical to establish IV access that
can accommodate large volumes of fluid. For burns >30% TBSA, a
central line for fluid and drug administration and blood sampling should
be considered. An arterial line also should be considered if frequent ABGs
or invasive BP monitoring is needed.
Each burn center has a preference for a replacement regimen. Fluid
replacement is accomplished with crystalloid solutions (usually lactated
Ringers), colloids (albumin), or a combination of the two. Paramedics
generally give IV saline until the patients arrival at the hospital.
The Parkland (Baxter) formula for fluid replacement is the most common
formula used, followed by the modified Brooke formula. It is important to
remember that all formulas are estimates and must be titrated based on
the patients physiologic response. For example, patients with an
electrical injury may have greater than normal fluid requirements.
Colloidal solutions (e.g., albumin) may be given. However, administration
is recommended after the first 12 to 24 hours post burn, when capillary

permeability returns to normal or near normal. After this time, the plasma
remains in the vascular space and expands the circulating volume. The
replacement volume is calculated based on the patients body weight and
TBSA burned.
Assessment of the adequacy of fluid resuscitation is best made using
clinical parameters. Urine output is the most commonly used parameter.

Understand the principles of wound care in the burn patient.

Partial-thickness wounds are pink to cherry red and wet and shiny with serous exudate. These
wounds may or may not have intact blisters and are painful when touched or exposed to air.
Full-thickness wounds will be dry and waxy white to dark brown/black and will have only minor,
localized sensation because nerve endings have been destroyed.
Emergent Phase
Nursing and Collaborative Management
Wound care
Should be delayed until a patent airway, adequate circulation, and adequate fluid
replacement have been established
Cleansing
Cleansing and gentle debridement, using scissors and forceps, can be
provided in a cart shower, a regular shower, or a patient bed/stretcher by
you and by physicians.
Debridement
May need to be done in the OR
Loose necrotic skin is removed.
Extensive surgical debridement is performed in the operating room (OR). During
debridement, necrotic skin is removed. Releasing escharotomies and fasciotomies can be
carried out in the emergent phase, usually in burn centers by burn physicians. Care
should be taken to accomplish these procedures as quickly and effectively as possible.
Patients find the initial wound care to be both physically and psychologically demanding.
Your emotional support is invaluable and assists in building an important sense of trust.

Infection is the most serious threat to further tissue injury.

The source of infection in burn wounds is the patients own flora,
predominantly from the skin (burned and unburned), respiratory tract, and
gastrointestinal (GI) tract. Prevention of cross-contamination from one
patient to another is a priority for all members of the health care team.
Open method
Burn is covered with a topical antibiotic with no dressing over the wound.

Multiple dressing changes or closed method

Sterilized gauze dressings are laid over a topical antibiotic.
These dressings are changed anywhere from every 12 to 24 hours to once
every 14 days, depending upon the product. Most burn centers support the
concept of moist wound healing and use dressings to cover burned areas,
with the exception of the burned face.
When open burns wounds are exposed, staff should wear
Disposable hats
Masks
Gowns
Gloves
When removing contaminated dressings and washing the dirty wound, you may use
nonsterile, disposable gloves.
Sterile gloves are used when applying ointments and sterile dressings.
In addition, the room must be kept warm (approximately 85 F [29.4 C]).
All PPE is removed and new applied before you treat another patient. This is necessary
to avoid transmitting organisms from one patient to anothera significant risk,
especially when there is more than one patient to a room.
Careful hand washing and the use of alcohol hand gel, both inside and outside each
patient room, are required to prevent cross-contamination.
After the dressing change is completed, the equipment and immediate environment are
thoroughly cleaned and disinfected. The use of plastic liners on equipment is helpful in
reducing potential contamination of equipment and facilitates cleaning.

Why is drug therapy important for the burn patient? What kind of drug therapy is used
and why?

Emergent Phase
Nursing and Collaborative Management
Drug therapy
Analgesics and sedatives
Morphine
Hydromorphone (Dilaudid)
Haloperidol (Haldol)
Lorazepam (Ativan)
Midazolam (Versed)
Analgesics are ordered to promote patient comfort.
Early in the postburn period, IV pain medications should be given because (1) onset of
action is fastest with this route, (2) GI function is slowed or impaired as the result of

shock or paralytic ileus, and (3) intramuscular (IM) injections will not be absorbed
adequately in burned or edematous areas, causing pooling of medications in the tissues.
When fluid mobilization begins, the patient could be inadvertently overdosed from the
interstitial accumulation of previous IM medications.
The need for analgesia must be reevaluated frequently as patients needs may change and
tolerance to medications may develop over time. Initially, opioids are the drug of choice
for pain control. When given appropriately, these drugs should provide adequate pain
management.
Sedative/hypnotics and antidepressant agents can also be given with analgesics to
control the anxiety, insomnia, and/or depression that patients may experience.
Analgesic requirements can vary tremendously from one patient to another. The extent
and depth of burn may not correlate with pain intensity.
Tetanus immunization
Tetanus toxoid is given routinely to all burn patients because of the
likelihood of anaerobic burn wound contamination. If the patient has not
received an active immunization within 10 years before the burn injury,
tetanus immune globulin should be considered.
Antimicrobial agents
Topical agents
Silver sulfadiazine (Silvadene)
Mafenide acetate (Sulfamylon)
Systemic agents are not usually used in controlling burn flora.
Initiated when diagnosis of invasive burn wound sepsis is made
After the wound has been cleansed, topical antimicrobial agents are applied and covered
with a light dressing.
Systemic antibiotics are not routinely used to control burn wound flora because little or
no blood supply to the burn eschar is available, and consequently, delivery of the
antibiotic to the wound is limited.
In addition, the routine use of systemic antibiotics increases the chance of development of
multiresistant organisms.
Some topical burn agents penetrate the eschar, thereby inhibiting bacterial invasion of
the wound.
Silver-impregnated dressings (Acticoat, Silverlon, Aquacel Ag) can be left in place
anywhere from 3 to 14 days and are used in many burn centers. Silver sulfadiazine
(Silvadene, Flamazine) and mafenide acetate (Sulfamylon) creams are also used.
Sepsis remains a leading cause of death in the patient with major burns, which may lead
to multiple organ dysfunction syndrome. Systemic antibiotic therapy is initiated when the
clinical diagnosis of invasive burn wound sepsis is made, or when some other source of
infection (e.g., pneumonia) is identified.

VTE prophylaxis
Low-molecular-weight heparin or low-dose unfractionated heparin is
started.
Those at high bleeding risk, with mechanical VTE prophylaxis with
sequential compression devices
For burn patients at risk for VTE (e.g., lower extremity burns, obesity), and if no
contraindications are known, it is recommended that low-molecular-weight heparin
(enoxaparin [Lovenox]) or low-dose unfractionated heparin (heparin [Hep-Lock])
should be started as soon as it is considered safe to do so.

For burn patients who have a high bleeding risk, it is recommended that mechanical VTE
prophylaxis with sequential compression devices and/or graduated compression
stockings be used until the bleeding risk is decreased and heparin can be started.

What is the importance of nutritional therapy and how is it addressed?

Nutritional therapy
Fluid replacement takes priority over nutritional needs.
Early and aggressive nutritional support within hours of burn injury
Decreases mortality and complications
Optimizes wound healing
Minimizes negative effects
Nonintubated patients with a <20% TBSA burn generally will be able to eat enough to
meet their nutritional requirements. Intubated patients and/or those with larger burns
require additional support.
Enteral feedings (gastric or intestinal) have almost entirely replaced the need for
parenteral feeding. Early enteral feeding, usually with the use of smaller-bore tubes,
preserves GI function, increases intestinal blood flow, and promotes optimal conditions
for wound healing.
The patient with large (>20% TBSA) burns can develop paralytic ileus within a few
hours as a result of the bodys response to major trauma.
If a large nasogastric tube is inserted on admission, gastric residuals should be checked
frequently to rule out delayed gastric emptying. Bowel sounds should be assessed every 8
hours.
In general, feedings can begin slowly at 20 to 40 mL/hr and can be increased to the goal
rate within 24 to 48 hours.

Hypermetabolic state
Resting metabolic expenditure may be increased by 50% to 100% above
normal.
Core temperature is elevated.
Caloric needs are about 5000 kcal/day.
Hypermetabolic state
Early, continuous enteral feeding promotes optimal conditions for wound
healing.
Supplemental vitamins and iron may be given.
A hypermetabolic state proportional to the size of the wound occurs after a major burn
injury.
Resting metabolic expenditure may be increased by 50% to 100% above normal in
patients with major burns.
Core temperature is elevated. Catecholamines, which stimulate catabolism and heat
production, are increased. Massive catabolism can occur and is characterized by protein
breakdown and increased gluconeogenesis.
Failure to supply adequate calories and protein leads to malnutrition and delayed
healing. Calorie-containing nutritional supplements and milkshakes are often given
because of the great need for calories. Protein powder can also be added to food and
liquids. Supplemental vitamins may be given as early as the emergent phase, with iron
supplements often started in the acute phase.

What are the pathophysiological changes in the acute phase?

The acute phase begins with the mobilization of extracellular fluid and subsequent
diuresis.
The acute phase is concluded when the burned area is completely covered by skin grafts,
or when the wounds are healed.

Pathophysiology
Diuresis from fluid mobilization occurs, and the patient is less edematous.
Bowel sounds return.
Healing begins when WBCs surround the burn wound and phagocytosis occurs.
Areas that are full- or partial-thickness burns are more evident than in the
emergent phase.

The patient may now become aware of the enormity of the situation and may
benefit from additional psychosocial support.

Necrotic tissue begins to slough.

Granulation tissue forms.
A partial-thickness burn wound heals from the edges.
Full-thickness burns must be covered by skin grafts.

Often, healing time and length of hospitalization are decreased by early excision and grafting.

What changes occur in the burn wound during this phase? What treatment is employed
during the acute phase?

Acute Phase
Clinical Manifestations
Partial-thickness wounds form eschar.
Once eschar is removed,
re-epithelialization begins.
Full-thickness wounds require debridement.

Partial-thickness wounds form eschar, which begins separating fairly soon after injury.
Once the eschar is removed, re-epithelialization begins at the wound margins and
appears as red or pink scar tissue.

Epithelial buds from the dermal bed eventually close in the wound, which then heals
spontaneously without surgical intervention, usually within 10 to 21 days.

Margins of full-thickness eschar take longer to separate. As a result, full-thickness

wounds require surgical debridement and skin grafting for healing.

How are systems affected during the acute phase? For example the fluid and electrolyte
system, musculoskeletal system, GI to name a few.

Acute Phase
Laboratory Values
Sodium
Hyponatremia can develop from
Excessive GI suction
Diarrhea

Manifestations of hyponatremia include weakness, dizziness, muscle cramps, fatigue,

headache, tachycardia, and confusion.
Water intoxication

The burn patient may also develop a dilutional hyponatremia called water intoxication.
To avoid this condition, the patient should drink fluids other than water, such as juice,
soft drinks, or nutritional supplements.
Sodium
Hypernatremia may develop following
Successful fluid replacement
Improper tube feedings
Inappropriate fluid administration
Hypernatremia may be seen following successful fluid resuscitation if copious amounts
of hypertonic solutions were required.
Manifestations of hypernatremia include thirst; dried, furry tongue; lethargy; confusion;
and possibly seizures.
Potassium
Hyperkalemia noted if patient has
Renal failure
Adrenocortical insufficiency
Massive deep muscle injury
Potassium
Hypokalemia can be caused by
Lengthy IV therapy without potassium
Vomiting, diarrhea
Prolonged gastrointestinal suction
Cardiovascular and respiratory systems
Same complications can be present in the emergent phase and may continue into
the acute phase. ABC.
Neurologic system
Usually no problems unless severe hypoxia or complications from electrical
injuries occur.
Disorientation
Combative
Hallucinations
Delirium
Transient state
Variety of causes have been considered.

Neurologically, the patient usually has no physical symptoms, unless severe hypoxia from
respiratory injuries or complications from electrical injuries occur.
However, some patients may demonstrate certain behaviors that are not completely
understood. The patient can become extremely disoriented, may withdraw, or may
become combative.
Delirium is more acute at night and occurs more often in the older patient.
Consultation with psychiatric or geriatric services is helpful in quickly diagnosing and
treating delirium or similar behaviors. You can then focus on strategies to orient and
reassure the confused or agitated patient.
This is a transient state, lasting from a day or two to several weeks.
Various causes have been considered, including electrolyte imbalance, stress, cerebral
edema, sepsis, sleep disturbances, and the use of analgesics and antianxiety drugs.
Musculoskeletal system
Decreased ROM
Contractures
Musculoskeletal system
The musculoskeletal system is particularly prone to complications during the acute
phase. As the burns begin to heal and scar tissue forms, the skin is less supple and pliant.
ROM may be limited, and contractures can occur.
Because of pain, the patient will prefer to assume a flexed position for comfort. You
should encourage the patient to stretch and move the burned body parts as much as
possible. Splinting can be beneficial to prevent/reduce contracture formation.

Gastrointestinal system
Paralytic ileus
Diarrhea
Constipation
Curlings ulcer

Gastrointestinal system
Paralytic ileus results from sepsis.
Diarrhea may be caused by the use of enteral feedings or antibiotics.
Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a
low-fiber diet.
Curlings ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial
lesions (including mucosal erosion). It is caused by a generalized stress response,
resulting in decreased production of mucus and increased gastric acid secretion. This
condition is due to decreased blood flow to the GI tract during the emergent phase.
The best measure for preventing Curlings ulcer is feeding the patient as soon as
possible. Antacids, H2-histamine blockers (e.g., ranitidine [Zantac]), and proton pump

inhibitors (e.g., esomeprazole [Nexium]) are used prophylactically to neutralize stomach

acids and inhibit histamine and the stimulation of hydrochloric acid (HCl acid) secretion.
Patients with major burns may also have occult blood in their stools during the acute
phase.
Endocrine system
Blood glucose levels
Insulin production
An increase in blood glucose levels may be seen transiently because of stress-mediated
cortisol and catecholamine release, resulting in increased mobilization of glycogen
stores, gluconeogenesis, and subsequent production of glucose.
An increase in insulin production and release is noted. However, the effectiveness of
insulin is decreased because of relative insulin insensitivity, leading to an elevated blood
glucose level.
Later, hyperglycemia can be caused by the increased caloric intake necessary to meet
some patients metabolic requirements. When this occurs, the treatment is supplemental
IV insulin, not decreased feeding. Serum glucose levels are checked frequently, and an
appropriate amount of insulin is given if hyperglycemia is present. Glucometers may be
used to assess blood glucose at the bedside; serum glucose samples are more accurate
than capillary blood analysis by glucometer.
As the patients metabolic demands are met and less stress is placed on the entire system,
this stress-induced condition is reversed.

How is wound care addressed? What about infection?

Infection
Localized inflammation, induration, and suppuration
Partial-thickness burns can become full-thickness wounds in the presence of
infection.
Wound infection may progress to transient bacteremia.
Patient may develop sepsis.
Condition becomes critical.
The bodys first line of defense, the skin, has been destroyed by burn injury. Pathogens
often proliferate before phagocytosis has adequately begun. The burn wound is now
colonized with organisms. If the bacterial density at the junction of the eschar with
underlying viable tissue rises to greater than 105/g of tissue, the patient has a burn
wound infection.

Invasive wound infections may be treated with systemic antibiotics based on culture
results.
Burn wound infection may progress to transient bacteremia and sepsis as a result of burn
wound manipulation (e.g., after showering and debridement) (see Chapter 67).
Manifestations of sepsis include hypothermia or hyperthermia, increased heart and
respiratory rate, decreased BP, and decreased urine output. Mild confusion, chills,
malaise, and loss of appetite may be observed. The WBC count will usually be between
10,000/l (10 109/L) and 20,000/l (20 109/L). Functional defects in the WBCs are
noted, and the patient remains immunosuppressed for a period after the burn injury.
The causative organisms of sepsis are usually gram-negative bacteria (e.g.,
Pseudomonas, Proteus organisms), putting the patient at further risk for septic shock.
When sepsis is suspected, cultures are immediately obtained from all possible sources,
including the burn wound, blood, urine, sputum, oropharynx and perineal regions, and
IV site.
However, treatment should not be delayed pending results of the culture and sensitivity
studies. Therapy will begin with antibiotics appropriate for the usual residual flora of the
particular burn center. The topical antibiotic in use may be continued or may be changed
to another agent.
At this stage, the patients condition is critical, requiring close monitoring of vital signs.
Collaboration with the Infectious Disease service is important to ensure appropriate
antibiotic coverage.
Acute Phase
Nursing and Collaborative Management
Wound care (contd)
Enzymatic debridement
Speeds up removal of dead tissue from healthy wound bed
Enzymatic debriders made of natural ingredients, such as papain, may be used for the
enzymatic debridement of burn wounds, which speeds up the removal of dead tissue from
the healthy wound bed.
Wounds are cleansed with soap and water or normal saline-moistened gauze to gently
remove the old antimicrobial agent and any loose necrotic tissue, scabs, or dried blood.
During the debridement phase, the wound is covered with topical antimicrobial creams
(e.g., silver sulfadiazine, silver-impregnated dressings).
When the partial-thickness burn wounds have been fully debrided, a protective, coarse or
fine-meshed, grease-based (paraffin or petroleum) gauze dressing is applied to protect
the re-epithelializing cells as they resurface and close the open wound bed.
Acute Phase
Nursing and Collaborative Management

Wound care (contd)

Appropriate coverage of the graft:
Gauze next to the graft followed by middle and outer dressings
Unmeshed sheet grafts used for facial grafts
Grafts are left open.
Complication: Blebs
If grafting is necessary, the meshed, split-thickness skin graft may be protected with the
same greasy gauze dressings next to the graft, followed by middle and outer dressings.
With facial grafts, the unmeshed sheet graft is left open, so it is possible for blebs
(serosanguineous exudates) to form between the graft and the recipient bed.
Blebs prevent the graft from permanently attaching to the wound bed. The evacuation of
blebs is best performed by aspiration with a tuberculin syringe and only by those who
have received instruction in this specialized skill.
Acute Phase
Nursing and Collaborative Management
Excision and grafting
Eschar is removed down to the subcutaneous tissue or fascia.
Graft is placed on clean, viable tissue.
Wound is covered with autograft.
Donor skin is taken with a dermatome.
Choice of dressings varies.
Current therapeutic management of full-thickness burn wounds involves early removal of
the necrotic tissue followed by application of split-thickness autograft skin.
This therapy has changed the management and mortality rate of burn patients. In the
past, patients with major burns had low rates of survival because healing and wound
coverage took so long that the patient usually died of sepsis or malnutrition. Because of
current earlier intervention, mortality and morbidity rates have been greatly reduced.
Many patients, especially those with major burns, are taken to the OR for wound excision
on day 1 or 2 (resuscitation phase). The wounds are covered with a biological dressing
or allograft for temporary coverage until permanent grafting can occur.
Devitalized tissue (eschar) is excised down to the subcutaneous tissue or fascia,
depending on the degree of injury. Surgical excision can result in massive blood loss, and
blood conservation techniques are used to limit this complication. Topical application of
epinephrine or thrombin, application of extremity tourniquets, and application of a new
fibrin sealant (Artiss) all work to decrease surgical blood loss.
Once hemostasis has been achieved, a graft is then placed on clean, viable tissue to
achieve good adherence.
Whenever possible, the freshly excised wound is covered with autograft (persons own)
skin.

Excision and grafting (contd)

Cultured epithelial autographs (CEAs)
Grown from biopsies obtained from the patients own skin
Used in patients with a large body surface burn area or those with limited
skin for harvesting
In the patient with large body surface area burns, only a limited amount of unburned skin
may be available as donor sites for grafting, and some of that skin may be unsuitable for
harvesting.
Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a
person with limited available skin for harvesting. CEA is grown from biopsy specimens
obtained from the patients own unburned skin.
This procedure is performed in some burn centers as soon as possible after admission on
suitable patients.
The specimens are sent to a commercial laboratory, where the biopsied keratinocytes are
grown in a culture medium containing epidermal growth factor. After approximately 18
to 25 days, the keratinocytes have expanded up to 10,000 times and form confluent sheets
that can be used as skin grafts.
The cultured skin is returned to the burn center, where it is placed on the patients excised
burn wounds.
Because CEA grafts are made only of epidermal cells, meticulous care is required to
prevent shearing injury or infection. CEA grafts generally form a seamless, smooth
replacement skin tissue. Problems related to CEA include a poor graft take due to thin
epidermal skin graft loss during healing, infection, and contracture development.
Acute Phase
Nursing and Collaborative Management
Pain management
Patients experience two kinds of pain.
Continuous background pain
Treatment-induced pain
Several drugs in combination
Morphine with haloperidol
Treatment-induced pain managed with potent, short-acting analgesic
One of the most critical functions you perform is individualized and ongoing pain
assessment and management. Many aspects of burn care cause pain. However, patients
experience moments of relative comfort if they receive adequate analgesia. A coordinated
understanding of both the physiologic and psychologic aspects of pain is essential if you
are to intervene with actions that are beneficial.
The first line of treatment is pharmacologic (see Table 25-14).
With background pain, a continuous IV infusion of an opioid will allow for a steady,
therapeutic level of medication. If an IV infusion is not present, slow-release twice-a-day

opioid medications (e.g., MS Contin) are indicated. Around-the-clock oral analgesics can
also be used. Breakthrough doses of pain medication need to be available, regardless of
the regimen selected. Anxiolytics, which frequently potentiate analgesics, are also
indicated and include lorazepam (Ativan) or midazolam (Versed).
For treatment-induced pain, premedication with an analgesic and an anxiolytic is
required via the IV or oral route. For patients with an IV infusion, a potent, short-acting
analgesic, such as fentanyl (Sublimaze) is useful. During treatment/activity, small doses
should be given to keep the patient as comfortable as possible.
Elimination of all the pain is difficult to achieve, and most patients indicate satisfaction
with tolerable levels of discomfort. Pain management is complex and ever-changing
throughout the patients hospital stay and after discharge.
Acute Phase
Nursing and Collaborative Management
Pain management (contd)
Nonpharmacologic strategies
Relaxation strategies
Visualization, guided imagery
Hypnosis
Biofeedback
Music therapy
They are not meant to be used exclusively to control pain but may help some patients
cope with the painful aspects of care, both in the hospital and after discharge.
Acute Phase
Nursing and Collaborative Management
Nutritional therapy
Meeting daily caloric requirements is crucial.
Caloric needs should be calculated by dietitian.
High-protein, high-carbohydrate foods
Favorite foods from home
Patients should be weighed regularly.
The burn patient is in a hypermetabolic and highly catabolic state as a result of the burn
injury. Decreasing catecholamine release by minimizing pain, fear, anxiety, and cold can
maximize patient comfort and conserve energy. Infection also increases metabolic rate.
If the patient is on a mechanical ventilator or is unable to consume adequate calories by
mouth, a small-bore feeding tube is placed and enteral feedings are initiated. When the
patient is extubated, a swallowing assessment should be performed by a speech
pathologist before the oral feeding is commenced.

The alert patient should be encouraged to eat high-protein, high-carbohydrate foods to

meet increased caloric needs.
If caregivers wish to bring in favorite foods from home, this should be encouraged.
Appetite is usually diminished, and constant encouragement may be necessary to achieve
adequate intake.
Ideally, weight loss should not be more than 10% of preburn weight. You need to record
the patients daily caloric intake using calorie count sheets, which are monitored by the
dietitian. Patients are weighed routinely to evaluate progress.

Physical and occupational therapy

Good time for exercise is during wound cleaning.
Passive and active ROM
Splints should be custom-fitted.

Rigorous physical therapy throughout burn recovery is imperative to maintain muscle

strength and optimal joint function.
A good time for exercise is during and after wound cleansing, when the skin is softer and
bulky dressings are removed.
Passive and active ROM should be performed on all joints. The patient with neck burns
must sleep without pillows or with the head hanging slightly over the top of the mattress
to encourage hyperextension.
Custom-fitted splints are designed to keep joints in functional position. These must be
reexamined frequently to ensure an optimal fit, with no undue pressure that might lead to
skin breakdown or nerve damage.

When does the rehab phase occur?

The rehabilitation phase begins when

Burn wounds are healed
Patient is able to resume a level of self-care activity
This can occur as early as 2 weeks or as long as 7 to 8 months after the burn injury.
Goals for this period are to (1) assist the patient in resuming a functional role in society,
and (2) rehabilitate from functional and cosmetic reconstructive surgery. Rehabilitationfocused activities that have been taking place during the earlier emergent and acute
phases now begin in earnest once the patients wounds have healed.

What pathophysiological changes are occurring in the burn patient?

Rehabilitation Phase
Pathophysiologic Changes
Burn wound heals either by primary intention or by grafting.
Layers of epithelialization begin to rebuild the tissue structure.
Collagen fibers add strength to weakened areas.
The new skin appears flat and pink.

In approximately 4 to 6 weeks, the area becomes raised and hyperemic.

Mature healing is reached in
6 months to 2 years.
Skin never completely regains its original color.
In approximately 4 to 6 weeks, the area becomes raised and hyperemic. If adequate ROM
is not instituted, the new tissue will shorten, causing a contracture.
Mature healing is reached in about 12 months, when suppleness has returned and the
pink or red color has faded to a slightly lighter hue than the surrounding unburned
tissue. It takes longer for more heavily pigmented skin to regain its dark color because
many of the melanocytes have been destroyed.
Frequently, the skin does not regain its original color. Paramedical cosmetic camouflage,
the implantation of pigment within the skin, can help even out unequal skin tones and
improve the patients overall appearance and self-image.

Discoloration of scar fades with time.

Pressure can help keep scar flat.
Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and
touch.
Healed areas must be protected from direct sunlight for 1 year.
Scarring has two components: discoloration and contour. The discoloration of scars will
fade somewhat with time. However, scar tissue tends to develop altered contours, that is,
it is no longer flat or slightly raised but becomes elevated and enlarged above the
original burned area.
It is believed that pressure can help keep a scar flat. Gentle pressure can be maintained
on the healed burn with custom-fitted pressure garments (e.g., Jobst garments). They
should never be worn over unhealed wounds and are removed only for short periods
while bathing.
These garments are worn up to 24 hours a day for as long as 12 to 18 months. The
patient typically experiences discomfort from itching where healing is occurring.
Application of water-based moisturizers and use of oral antihistamines (e.g.,
diphenhydramine [Benadryl]) help reduce the itching. Massage oil, silicone gel sheeting
(e.g., Biodermis), gabapentin (Neurontin), and injectable steroids also may be helpful.

As old epithelium is replaced by new cells, flaking will occur. The newly formed skin is
extremely sensitive to trauma. Blisters and skin tears are likely to develop from slight
pressure or friction.
Additionally, these newly healed areas can be hypersensitive or hyposensitive to cold,
heat, and touch. Grafted areas are more likely to be hyposensitive until peripheral nerve
regeneration occurs. Healed burn areas must be protected from direct sunlight for about
3 months to prevent hyperpigmentation and sunburn injury.
Rehabilitation Phase
Complications
Skin and joint contractures
Most common complications during rehab phase
Positioning, splinting, and exercise should be used to minimize contracture.
A contracture (an abnormal condition of a joint characterized by flexion and fixation)
develops as a result of shortening of scar tissue in the flexor tissues of a joint.
Areas that are most susceptible to contracture formation include the anterior and lateral
neck areas, axillae, antecubital fossae, fingers, groin areas, popliteal fossae, knees, and
ankles.
These areas encompass major joints. Not only does the skin over these areas develop
contractures, but underlying tissues, such as the ligaments and tendons, have a tendency
to shorten during the healing process.
Because of pain, the patient will prefer to assume a flexed position for comfort. This
position predisposes wounds to contracture formation. Positioning, splinting, and
exercise should be instituted to minimize this complication. These procedures should be
continued until the skin matures.
Therapy is aimed at the extension of body parts because the flexors are stronger than the
extensors. Burned legs may be wrapped with elastic (e.g., tensor/Ace) bandages to assist
with circulation to leg graft and donor sites before ambulation. This additional pressure
prevents blister formation, promotes venous return, and decreases pain and itchiness.
Once the skin is completely healed and less fragile, custom-fitted pressure garments
replace the elastic bandages.

What nursing care and treatment is implemented during this phase? Consider every system
in the body that is being affected during this phase.

Rehabilitation Phase
Nursing and Collaborative Management
Both patient and family actively learn how to care for healing wounds.

An emollient water-based cream should be used.

Cosmetic surgery is often needed following major burns.
During the rehabilitation phase, both patient and caregiver are actively encouraged to
participate in care. Because the patient may go home with small, unhealed wounds,
education and hands-on instruction in dressing changes and wound care will be
needed.
If needed, home care nursing services should be arranged to assist with care for the first
few weeks post discharge.
An emollient water-based cream (e.g., Vaseline Intensive Care Extra Strength) that
penetrates into the dermis should be used routinely on healed areas to keep the skin
supple and well moisturized, which will decrease itching and flaking.
Oral antihistamines may be used if itching persists.
Postburn reconstructive surgery is frequently required following a major burn. It is
important for the patient to understand the need for or possibility of further surgery
before leaving the hospital.
Emotional Needs of the Patient and Family
A common emotional response is regression.
Early psychiatric intervention
Assess psychoemotional cues.
Issue of sexuality must be met with honesty.
Family and patient support groups
A common emotional response is regression. The patient may revert to behavior that
helped in coping with stressful situations in the past. This response can be healthy and is
usually short term in nature. Major emotional challenges confront patients and
caregivers throughout the burn patients recovery, and perhaps for years to come. As
more and more independence is expected from the patient, new fears must be confronted:
Can I do it? Am I a desirable partner/parent? Open and frequent communication
among the patient, caregivers, close friends, and burn team members is essential.
Burn survivors frequently experience thoughts and feelings that are frightening and
disturbing, such as guilt about the burn incident, reliving the experience, fear of death,
concern about future therapy and surgery, frustrations with ongoing discomfort and
wound breakdown, and, perhaps, hopelessness about the future. Caregivers may share
some or all of these feelings. At times, they may feel helpless to assist their loved one.
Continued support from trusted and familiar burn team members, particularly you and
social worker staff, is essential.
The stress of the burn injury occasionally precipitates a psychiatric/psychological crisis.
Many patients realize that this experience is beyond their ability to cope. Assessment by a
psychiatrist, who can prescribe appropriate medication, if needed, and can begin shortterm counseling is frequently helpful. Early psychiatric intervention is essential if the

patient has been previously treated for a psychiatric illness, or if the injury was a suicide
attempt. The diagnosis of posttraumatic stress disorder is made in a number of burn
patients.

______________________________________________________________________________
Know the basic statistics of cancer in the US.

Incidences of lung, colorectal, and oral cancer have

Whereas incidences of Non-Hodgkins Lymphoma and skin cancer have
Higher in men than women
Incidence and death rates are higher in African Americans than in whites and other
minorities.
Second most common cause of death in the United States after what?

Understand the pathophysiological changes occurring in the development of cancer.

Figure 16-3

Cancer
Disease process that begins when a cell is transformed by mutation of cellular DNA
Impacts;
Proliferation (cell growth)
Cancer cells tend to divide haphazardly and indiscriminately.
No contact inhibition
Differentiation (unique function of the cell)
Cancer cells are capable of infiltrating far way tissues; Metastasis
Defect in Cellular Proliferation
Once mutated
Cells can die from damage or by initiating programmed cellular suicide
(apoptosis).
Can recognize damage and repair itself
Can survive and pass on damage to two or more daughter cells
Surviving mutated cells have potential to become malignant.

Two types of genes that can be affected by mutation are

Protooncogenes
Regulate normal cellular processes such as promoting growth
Tumor suppressor genes
Suppress growth
Tumors can be classified as benign or malignant neoplasms
Benign neoplasm
Well differentiated
Usually encapsulated
Expansive mode of growth
Characteristics similar to parent cell
Metastasis is absent.
Rarely recur
The ability of malignant tumor cells to invade and metastasize is the major difference between
benign and malignant neoplasms.

Malignant neoplasm
May range from well differentiated to undifferentiated
Able to metastasize
Infiltrative and expansive growth
Frequent recurrence
Moderate to marked vascularity
Rarely encapsulated
Becomes less like parent cell
Development of Cancer
Likely to be multifactorial
Origin of cancer may be
Genetic
Chemical
Environmental
Viral or immunologic
May arise from causes not yet identified
Development of Cancer
Initiation
Mutation of cells genetic structure
Mutated cell has the potential to develop into clone of neoplastic cells.
Promotion
Characterized by reversible proliferation of altered cells
Activities of promotion are reversible.

 Obesity
Smoking, alcohol
Dietary fat
Latent period
May range from 1 to 40 years
Length of latent period associated with mitotic rate of tissue of origin and
environmental factors
For disease to be clinically evident, tumor must reach a critical mass that can be
detected.
Progression
Characterized by
Increased growth rate of tumor
Invasiveness
Metastasis
Most frequent sites of metastasis are lungs, brain, bone, liver, and adrenal glands.
Progression
Metastasis process begins with rapid growth of primary tumor.
Develops its own blood supply (angiogenesis)
Certain segments of primary tumor can detach and invade surrounding
tissues.

Development of metastasis

Fig. 16-5. The pathogenesis of cancer metastasis. To produce metastases,

tumor cells must detach from the primary tumor and enter the circulation,
survive in the circulation to arrest in the capillary bed, adhere to capillary
basement membrane, gain entrance into the organ parenchyma, respond
to growth factors, proliferate and induce angiogenesis, and evade host
defenses.

Understand the role of the immune system in the development of cancer.

Cytotoxic T cells
Kill tumor cells directly
Produce cytokines
Natural killer cells and activated macrophages can lyse tumor cells.
B cells produce antibodies directed to tumor surface antigens.
Immunologic escape

Mechanism by which cancer cells evade immune system

Suppression of factors that stimulate T cells
Weak surface antigens allow cancer cells to sneak through surveillance.

Know the different ways to classify cancer. Table 16-5 (p. 269)
Clinical staging classifications
0: Cancer in situ
1: Tumor limited to tissue of origin; localized tumor growth
2: Limited local spread
3: Extensive local and regional spread
4: Metastasis
TNM classification system
Anatomic extent of disease is based on three parameters:
Tumor size and invasiveness (T)
Spread to lymph nodes (N)
Metastasis (M)

List and explain the primary and secondary prevention and how it pertains to cancer.
Primary prevention focus is with reducing cancer risk in healthy people.
Secondary prevention focus is detection and screening to achieve early diagnosis and
intervention.
Primary Prevention
Avoid known carcinogens.
Lifestyle and dietary changes to reduce cancer risk (obesity, alcohol, decrease dietary fat,
stop smoking)
Public and patient education
Factors that can influence development of cancer
Oncogenic viruses and bacteria
Sunlight, radiation, chronic irritation
Chemical agents: tobacco, asbestos
Certain Medications (including Chemotherapy)
Genetic and familial factors
Diet
Hormones
Age

Secondary Prevention

Identification of patients at high cancer risk

Cancer screening
Self-breast exam
Self-testicular exam
Screening colonoscopy
Pap test
Public and patient education

How is cancer diagnosed? Pt Complaints Acronym CAUTION

Change in bowel or bladder habits
Any sore that does not heal
Unusual bleeding or discharge
Thickening or lump in breast or elsewhere
Indigestion
Obvious change in wart or mole
Nagging cough or hoarseness

Diagnosis of Cancer
Diagnostic Tests
MRI, CT
Radioisotope scans
Tumor marker (CEA, PSA, CA125),
Genetic markers (BRCA-1, BRCA-2)
Endoscopy
Biopsy
Biopsy
Incisional biopsy (scalpel or dermal punch)
Excisional biopsy (therapeutic and diagnostic); removes entire tumor
Needle biopsy
MOHS surgical technique (especially good for cosmetic areas)
Sentinel node

How is cancer treated? List the different modalities and explain each.

Cancer Management Goals of surgical procedures

Cure
Control

Palliation; focus is on quality of life at the highest level for the longest possible period of
time. Examples include;
Debulking of tumor to relieve pressure
Colostomy for the relief of bowel obstruction

How does radiation control or eradicate cancer? What are the effects of radiation on the
body systems? What nursing care is needed for the patient who receives this treatment?
Radiotherapy: interrupt cellular growth
External radiation (teletherapy)
Total dose (rads) based on tumor size/type is divided into daily fractions.
Treatment is typically delivered 1 x day for 2-8 weeks
Internal radioisotope
Brachytherapy; implanted, IV or swallowed
Unsealed; not completely confined to one area. Excreted in body fluids,
usually within 48 hours
Sealed; solid implant. Emits radiation (Excreta does not). Left in place
until prescribed amount of radiation delivered.
Radiation Table 16-12 (p. 281)
Will injure, kill surrounding tissue
Systemic fatigue, malaise, HA, N/V
Effect on the GI system
Stomatitis, dysphagia, dry mouth, loss of taste, N/V , diarrhea
Effect on bone marrow
Myelosuppression- pancytopenia
Systemic effects
Fatigue, anorexia
Long-term effects and tissue changes
Fibrotic changes result of decreased vascular supply
Nursing Care of the Radiation Pt.
Explain procedure, what to expect (area is marked)
Do not remove radiation markings
Assess skin and oral mucosa
Suggest strategies to offset side effects such as fatigue and anorexia
Goals; promote healing of wound, provide comfort measures, prevent infection
Skin should be protected against temperature extremes. Avoid tight clothing, irritating
chemicals.
Wash area with warm water
Do not use ointments or powders unless prescribed

 Wear soft clothing

Do not suntan or heat/cold expose
Client with a sealed source
Private room
Caution sign on door
Organize nursing tasks
Limit time to 30 minutes per shift
Wear a lead shield
Dosimeter badge
Time/distance/shielding (lead)
A dislodged radiation source
Do not touch with bare hands
Use long handled forceps to pick up and place in lead container
How does chemotherapy control or eradicate cancer? What are the major classifications of
chemotherapeutic agents? What nursing precautions are needed when delivering
chemotherapy? What effects are seen in each body system in a chemotherapy patient?
What nursing care is needed to assist the chemotherapy patient?
Chemotherapy
Agents used to destroy tumor cells by interfering with cellular function and replication
Cure
Control
Palliative
Several factors determine response:
Mitotic rate of tissue of origin
Rapid mitotic rate, better response
Size of tumor
Smaller tumor, greater response
Age of tumor
Younger tumor, greater response
Location of tumor
Few agents cross blood-brain barrier.
Presence of resistant tumor cells
Resistant malignant cells pass resistance to daughter cells, which continue
to proliferate and remain resistant.
Classification of Drugs

Classified by
Molecular structure
Mechanism of action
Two major categories
Cell cycle phasenonspecific
Cell cycle phasespecific
Typically given in combination why? (p. 277)
Combination Chemotherapy
Combination of drugs help prevent tumor cell resistance & minimize occurrence/severity
of side effects!
Cell cycle phasenonspecific Table 16-7 (p. 274-275)
Alkylating agents
Nitrosoureas
Platinum drugs
Antitumor antibiotics
Corticosteroids
Hormone therapy
Cell cycle phasespecific
Antimetabolites
Mitotic inhibitors
Topoisomerase inhibitors
Chemotherapy nursing concerns
May pose an occupational hazard
Drugs may be absorbed through
Skin
Inhalation during preparation, transportation, and administration
Only properly trained personnel should handle drugs.
Chemotherapy
Can be delivered administered in a variety of routes
Intravenous, Intrathecal, intraarterial, intraperitoneal
What is the Nadir? When does it occur? What does it mean for your patient? (p. 280)
Adverse Effects of Chemotherapy- Table 16-12 (p. 281- 282)
GI effects: nausea and vomiting, diarrhea, mucositis,
Hematopoietic effects: myelosuppression
Renal damage
Cardiopulmonary system: potential cardiac toxicities
Reproductive system: potential sterility, potential reproductive cell abnormalities
Mitigating chemotherapy side effects
Mucositis

 Meticulous oral care, Anesthetic gels, Magic mouthwash

Thrombocytopenia
Platelet infusion
N/V
Prophylactic antiemetics, Monitor F/E
Fatigue
Neutropenia; neutropenic precautions
Fatigue
Nearly universal symptom
Manage other symptoms
Walking program or other activity helps mood
Debilitating cycle of fatigue-depression-fatigue
Alopecia
Radiation and chemotherapy
Usually reversible
Can grow back as a different color and texture
Nursing Care
Vesicants/extravasation
If it happens;
Stop drug
Apply ice (usually)
Inject neutralizing agent (into same iv cath)
Careful handling of drug; protect yourself
Extravasation Injury due to Chemotherapy
Rx to Manage Side Effects
Antiemetics (Zofran)
Granulocyte colony stimulating factor (GCSF aka neupogen)
Stimulates bone marrow to produce WBC
Pain management; Morphine, Fentanyl
Typically scheduled around the clock and a PRN for breakthrough pain
Describe bone marrow transplantation. What are the different types? What is the procedure?
What are the complications?
Bone Marrow Transplantation
A standard treatment for leukemia with closely matched donor
Types of BMT:
Allogenic (sibling)
Autologous (own stem cells)

Syngeneic (twin)

Procedure
Cells harvested: donor or self
Body conditioned; chemo and radiation to eradicate bone marrow producing cells
Bone Marrow rescue; Donated, healthy cells transplanted via IV 24-48 hours after
chemotherapy eliminated from body
Takes 2-4 weeks for the transplanted marrow to start producing engraftment. Protective
isolation necessary!!
Complications
Infections
Graft versus Host disease (p. 292)
Donor T cells attack and destroy vulnerable tissues (skin, GI tract, liver)
7-30 days after transplant
Hard to treat, corticosteroids, immunosuppression drugs better for prevention
Radiation of blood products before administration may be helpful
Peripheral stem cell transplant use more mature cells thus recovery shorter and
fewer/less severe complications
What surgical treatments are employed for the cancer patients? Describe their benefits.

Diagnostic surgery
Biopsy: excisional, needle, incisional
Tumor removal: wide excision, local excision
Prophylactic surgery
Reconstructive surgery
Debulking
palliative

What is an oncological emergency? List the most prevalent ones seen in practice. What are the
clinical manifestations? What treatments are used to combat these problems?

Superior vena cava syndrome; Obstruction of vena cava by tumor or clot.

s/s; facial edema, distended neck veins
Most common causes; cancers of the lung, breast
Treatment; radiate site.
Spinal cord compression; tumor presses on cord
s/s back pain, numbness in extremities, bowel/bladder problems
Tumor Lysis syndrome
Caused by rapid release of chemicals/cellular components as a response to chemo

Rise in phosphate drives calcium levels down

Uric acid levels increases; causes ARF
Four hallmark signs are; hyperuricemia, hyperphosphatemia, hyperkalemia, and
hypocalcemia
Primary goal; prevent ARF, treat electrolyte disturbances
Allopurinol for uric acid levels
Hydration for ARF
Syndrome of inappropriate ADH (SIADH)
Abnormal or sustained production
Cancer cells are able to manufacture, store, and release ADH.
Some chemotherapeutic agents stimulate release.
Treatment of fluid restriction or IV of 3% NaCl in severe cases
Monitor sodium level because correcting SIADH rapidly may result in seizures or
death
Occurs most frequently in carcinoma of the lung (especially small cell lung
cancer)
Hypercalcemia
Parathyroid hormonelike substance secreted from cancer cells in absence of
bony metastasis
Signs include
Apathy, depression, fatigue, weak muscles
Electrocardiogram changes, polyuria, nocturia, anorexia, nausea, vomiting
Can be life-threatening
Treatment is aimed at primary disease.
Acute hypercalcemia is treated by
Hydration
Diuretic administration
Bisphosphonate
Other oncologic emergencies
Septic shock
Disseminated intravascular coagulation (DIC)
Cardiac Tamponade
Carotid artery rupture
Describe the proper management of pain in the cancer patient.

Patient report should always be believed and accepted as primary source for pain
assessment data.
Drug therapy should be used to control pain.

Moderate to severe pain occurs in approximately 50% of patients who are receiving
active treatment for their cancer and in 80% to 90% of patients with advanced cancer.
Fear of addiction is unwarranted.
Numerous drug options for pain management
Nonpharmacologic interventions, including relaxation therapy and imagery, can be used
effectively.

Psychologic Support
Emphasis is placed on maintaining optimal quality of life.
Positive attitude of patient, family, and health care providers can have a positive impact
on the patients quality of life.
May also influence prognosis
List and describe the different forms of breast cancer. What therapies and surgical treatments are
used for breast cancer? What is lymphedema and why is it a problem for the breast cancer
patient?
Breast Cancer (p. 1311-1319)
Types
Non-invasive Ductal Carcinoma In Situ
If left untreated can proceed to invasive; most often infiltrating ductal cell
carcinoma
Pagets Disease
Rare, involves nipple/areola lesion (discharge, ulceration)
Inflammatory breast cancer; most malignant of all types
Aggressive and fast growing
Can be mistaken for an infection (mastitis)
Surgical interventions

Adjuvant therapy
Need is dependent on type and stage of cancer
Radiation
Chemo
Hormonal therapy
Neutropenia < 1000-1500 **
Causes: iatrogenic: cycles of radiation and chemo combined increases risk
s/s to look out for: fever (in an infection; classic signs of inflammation may not occur).
Worry about sepsis
Care: meticulous care of all IV sites and caths. Low threshold to culture
Oral and peri care important
Good hand washing always
Encourage to avoid crowds and sick people

 Avoid uncooked foods

Hormonal therapy
Tamoxifen; antiestrogen agent
Given as a chemo prevention agent in some patients
Prophylaxis in women at high risk for Breast CA
Know drug alerts for
Adriamycin (p. 1318)
Tamoxifen (p. 1319)
Lymphedema
Can happen after lymph node dissection
To prevent lymphedema during Post op period:
exercises designed to maintain muscle tone and improve lymph flow.
Affected arm should never be dependent even while sleeping
No BP readings, venipuncture/ or IVs on affected arm
Elastic bandages should not be used in early po period
Protect the arm from any trauma that could lead to infection
List and describe the different types of hematologic cancers. List the clinical
manifestations. Describe their pathophysiology. What age groups and demographics do
they affect?
Hematologic cancers (p. 694-704)

Leukemia
Hematopoietic malignancy with unregulated proliferation of leukocytes:
Acute myeloid leukemia
Chronic myeloid leukemia
Acute lymphocytic leukemia
Chronic lymphocytic leukemia
Acute Myeloid Leukemia (AML)
Defect in the stem cells that differentiate into all myeloid cells: monocytes, granulocytes,
erythrocytes, and platelets
Most common nonlymphocytic leukemia accounts for 85 % of adult acute cases
Affects all ages with peak incidence at age 60
Prognosis is variable
Manifestations: fever and infection, weakness and fatigue, bleeding tendencies, pain from
enlarged liver or spleen, hyperplasia of gums, and bone pain
Treatment is aggressive chemotherapy: BMT
Acute Lymphocytic Leukemia
Uncontrolled proliferation of immature cells from lymphoid stem cell
Most common in young children, boys more often than girls

Prognosis is good for children; 80% event-free after 5 years, but survival drops with
increased age
Manifestations: liver, spleen, and bone marrow pain, fever, bleeding, weakness, fatigue
Treatment: chemotherapy, BMT
Chronic Lymphocytic Leukemia
Malignant B lymphocytes, most of which are mature but nonfunctional, may escape
apoptosis, resulting in excessive accumulation of cells
Most common form of leukemia in adults
More common in older adults and affects men more often
Survival varies from 2 to 14 years depending upon stage
Manifestations: lymphadenopathy, hepatomegaly, splenomegaly; in later stages, anemias
and thrombocytopenia; autoimmune complications fever, sweats, and weight loss
Treatment: early stage may require no treatment, chemotherapy
Clinical manifestations
Result from bone marrow failure
Overcrowding by abnormal cells
Inadequate production of normal elements
Predisposed to anemia, thrombocytopenia
Leukemia cells begin to infiltrate organs
Splenomegaly, lymphadenopathy, bone pain, meningenal irritation
Induction therapy
Goal to induce remission
High doses of chemo
Risk of severe bone marrow reduction
If induction successful than maintenance therapy of same drug every 3-4 weeks for
prolonged period of time
Nursing Diagnoses
Risk for bleeding
Risk for impaired skin integrity
Impaired gas exchange
Impaired mucous membrane
Imbalanced nutrition
Acute pain
Fatigue and activity intolerance
Impaired physical mobility
Risk for excess fluid volume
Diarrhea
Risk for deficient fluid volume

 Self-care deficit
Anxiety
Disturbed body image
Potential for spiritual distress
Grieving
Deficient knowledge
Goals
absence of complications,
maintenance of adequate nutrition, activity tolerance,
ability for self-care
cope with the diagnosis and prognosis,
positive body image
understanding of the disease process and its treatment
Lymphoma
Neoplasm of lymph
Hodgkins lymphoma
Non-Hodgkins lymphoma
Hodgkins Lymphoma
Suspected viral etiology (EBV); familial pattern; incidence occurs in early 20s and again
after age 50
Excellent cure rate with treatment
Onset of symptoms usually insidious
Manifestations: painless, moveable lymph node enlargement; pruritus; fever, sweats, and
weight loss
Treatment is determined by stage of the disease and may include chemotherapy and/or
radiation therapy
Non-Hodgkin's Lymphoma (NHL)
Lymphoid tissues become infiltrated with malignant cells that spread unpredictably;
Incidence increases with age; the average age of onset is 50 to 60
Prognosis varies with the type of NHL
Treatment is determined by type and stage of disease and may include interferon,
chemotherapy, and/or radiation therapy
Multiple Myeloma
Malignant disease of plasma cells in the bone marrow with destruction of bone
Median survival is 3 to 5 years; there is no cure
Manifestations: bone pain, osteoporosis, fractures, elevated serum protein, hypocalcemia,
renal damage, renal failure, anemia, fatigue, weakness,
Treatment may include chemotherapy, corticosteroids, radiation therapy