NURS 3375 NURSING OF ADULTS WITH COMPLEX NEEDS
Exam 3 notes - Lecture and review for exam 3 NEW UPDATE
University of Texas at Arlington
Exam 3 Study Guide
BURNS
1. Explain the factors that affect the severity of burn injury.
2. Describe the local and systemic effects of a major burn injury.
3. Compare priorities of care and potential complications for each phase of burn
recovery: emergent/acute/rehab.
4. Plan fluid replacement requirements during the emergent/resuscitative phase of a burn injury
using the ABA Formula and the Rule of Nines.
5. Discuss the nurse’s role in burn wound management during the acute/intermediate phase of burn
care.
6. Examine the rehabilitation phase of burn management.
Factors affect the severity of the burn – age, depth of skin destruction, extent of the burn, presence of
inhalation injury, presence of other injury, and past medical hx ➔ fluid resuscitation required
Burn causes fluid volume deficit d/t capillary permeability increases ➔ water, sodium, plasma proteins leak
out of blood vessel into third spaces (tissue space)
Common complication
- Respiratory complications:
o Release inflammatory mediators ➔ increased cap permeability ➔ edema of airway ➔
airway obstruction
o Indications of inhalation injury = stridor (sound on inhalation), wheezing, carbon particles in
sputum, poor oxygenation, pulmonary edema
o Rapid fluid resuscitation may cau fluid overload ➔ poor oxygenation
o ARDS (S&S pf pulm edema, rales, evidence of infiltration on CXR, refractory hypoxemia,
vent high pressure alarm sounding = stiffen of the lungs ( low compliance) and high
resistance. **review VAP
- CV complications: hypo/hypervolemia
o hypovolemia (inadequate fluid volume replacement) = S&S of hypovolemia – low BP,
PAWP, CVP, PAD.
▪ During emergent phase – SBP need to be higher than 90, HR < 120
▪ Hypovolemia may cause hypoperfusion ➔ hypoxia ➔ ass metabolic acidosis ➔
Assess HYPERKALEMIA (muscle weakness, ECG changes)
o Volume overload d/t vigorous fluid replacement = high CVP, PAWP, PAD, rales ➔
assess weight daily ➔ assess HYPOKALEMIA (fatigue, muscle weakness)
- Circulatory
o Increase inflammatory mediators ➔ hypermetabolization ➔ high O2 and glucose
consumption +
catabolism of muscle and bone + immune dysfunction + insulin resistance = stress
response (d/t elevated cortisol)
o BRC destruction ➔ may cause anemia BUT plasma loss may cause evevated Hct
o Prolonged clotting times d/t plasma loss (contain clotting factors and platelets)
o Plasma loss ➔ MORE fluid shifts and edema ➔ occlude blood supply ➔ tissue
ischemia = compartment syndrome (paresthesia, pain, pallor, poikilothermia,
paralysis, pulselessness)
▪ Elevate extremity but NOT above the heart level
▪ Tx: Escharotomy/ scalpel incision
,- Renal
o Pre-renal AKI ➔ hypovolemia ➔ assess BUN/cre ➔ keep UO 0.5-1mL/kg/hr. **adequate
UO is the BEST indicator of adequate fluid resuscitation
o Intra-renal AKI ➔ myoglobin realeased into circulation = injured muscle (rhabdomyolysis) +
hgb
from damaged RBCs ➔ these two block and damage nephron
▪ Tx: ensure adequate fluid, assess for dark urine (S&S of myoglobinuria), reassess
hydration status (fluid are indicated until the urine is no longer red)
, o Electrolyte
▪ Hyponatremia d/t plasma loss + excess IV fluid/ GI suction.
• S&S: weak/dizzy/ muscle cramps, confusion
▪ Hypernatremia ➔ hypertonic IV/ hypovolemia
• S&S: comfusion/seizures, thirst, furry tongue
▪ Hyper/hypokalemia (think cardiac)
- GI
o If burn > 20%, NGT is inserted, low intermittent suction to reduce nausea from paralytic
ileus (low BS)
o Diarrhea (from tube feed/ meds) ➔ volume and electrolyte loss
o Constipation (from immobility/ meds)
o Curling’s stress ulcer. S&S abdominal pain, dark stool
o Imbalanced nutrition (emergent, and intermediate phases) ➔ early nutritional support ➔
decrease motality, sepsis, and optimize wound healing ➔ increase protein/ cal intake.
Feed via enteral route ASAP but slowly 20-40ml/hr (jejunal tube feed utilized)
- Musculoskeletal/ integumentary
o Inability to thermoregulate ➔ decrease temp ➔vasoconstriction ➔ ischemia
o Prevent ischemic/ infection to ears = don’t use pillows, assess cap refill at ears
o Tetanus prophylaxis
o Prevent infection = cleanse and debride/ remove necrotic/dead tissue
o Topical antimicrobials used when reduce blood supply is suspected
o Prevent contractures = bedside ROM exercises. PT should begin immediately
o Scarring ➔ depression ➔ chaplain
Phases:
- Emergent/ resuscitative phase = begin at onset of injury, ends at completion of fluid resuscitation
(first 24hr)
- Acute/ intermediated = beginning of diuresis to wound closure
- Rehab = wound closure to return of optimal physical and psychosocial adjustment
