N144 MSK Burns Abuse Lecture

8/14/2019 N144 MSK Burns Abuse Lecture

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MSK/Burns/Abuse Lecture 11/09/2009

Paper: 10 pages doesnt include cover page, copy of procedure &

references etc. 10 pages Max but can be fewer. Can turn into Moodle or

bring in a paper copy on Monday 10/23.

Case Study: What are we going to assess for this patient in addition to

what we have?

CMS assess

Pain level

Risk Factors for this fall: Osteoporosis, Age, Thin & Frail, Nutritional

status, Hx previous fx

What else is worrisome for this geriatric pt with a fx?

Prolonged immobility leading to loss of function

How do we prevent osteoporosis

Eliminate carbonated beverages, walking 30 mins 5-6x/week,

calcium supplements

Types of Fx (See slide for illustration)

Long Bone fx

Small Bone fx

Spine fx


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Spinous processes

Vertebral body

Types of Traction

Bucks: non-invasive, 5-10 lbs, prevents pain b/c decreases muscle

spasm. Maintains alignment of the bone.

Skeletal traction: pins into bone & contraption that attaches the

weight

Concerns for a pt in traction?

Pressure ulcers can prevent by turning as long as traction

stays aligned, usually need 2 ppl one to hold pt traction in

place & one to turn

CMS assess the distal extremity

Infection (for skeletal traction)

Priority Assessment

CMST: Circulation (cap refill, pulse), Motion, Sensation,

Temperature

Other assessments: circumference of extremity & the quality of pin

sites s/b w/o signs of infxn


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Case Study 8 hours later

Priority concern now: sensation to L hand extremity pale, cool,

decrease in sensation, pain w/passive movement

Compartment Syndrome

Limb-threatening occurrence: high priority for us

If concerned about this would measure circumference regularly to

ensure its not getting bigger

Surgeon can insert a needle into compartment to get a pressure

reading on it.

Fasciotomy done if d/t compartment itself, Bivalve cast (clamshell

cast) if d/t tightness of the cast

Prevention of compartment syndrome: Elevate the limb! And dont

overload with fluid resuscitation.

Question: what to do when pt has cool/pale distal extremity to injury

in a cast

Reinforce Dressing

Remove pillow & lay the leg flat


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Warm the foot w/heating pad & assess pulse w/doppler (dont do

this b/c heating pad will make the extremity more edematous!)

Elevate the leg higher & apply ice

Case Study: 24 hours later

Priority assess when she starts to become restless? Check

oxygenation status since restlessness is the first indicator of O2.

What are your priority actions?

O2 via NC (already getting 2L)

Notify the physician because Fat Embolism! Altered mental

status is one of the first signs of this!

Fat Embolism

Assessment

Altered mental status

Respiratory distress (tachypneic, O2 sat)

Truncal Petechiae b/c fat globules block the microcirculation

Nursing Care

O2

Monitor circulation


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Hydration

1-3% of pt with single long bone fx get these

Trunchal petechiae is 20-50% (???)

Prevent by early immobilization of the fx & operative fixation to

repair the break

What other complications are orthopedic patients at risk for?

DVT most common complication of ortho surg & LE fx

Infection osteomyelitis especially

Pneumonia

Types of Fixation See Slide

ORIF - Open reduction internal fixation

IMN Intramedullary nail

External fixation Ex Fix

Fusion (spine) seen very rarely in other extremities

Joint replacement

Case Study 3 days later


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Hip Precautions for this patient cant flex more than 90 degrees,

keep hips abducted & avoid crossing legs. These pts given

elevators to go over the toilet so they are not bending down so

deep to go to the bathroom. These precautions done for 6-8 weeks

(see slide for pictures)

Other d/c issues

Meds: pain meds, ongoing DVT prophylaxis

Outpatient PT/OT & other f/up appointments

They know the signs of infxn

Types of weight-bearing permitted: NWB or TDWB

Return to Case Study

Priority Assessments

LOC, Pain, Fluid Status ( AEB low BP & LOC), Breathing

Approach to care of the burn patient

Identify degree of burn & calculate percentage burns

Calculate fluid requirements

Maintain ABCs

Initiate & continue wound care


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This pt would go to the ICU discussion of which pts go to ICU &

which would go to Med Surg unit

Rule of 9s: circumferential scald burns from mid abdomen to toes

bilaterally

For our patient calculates out to 65%

Degrees of Burn Injury

Superficial (1st

degree)

Epidermis Only

Heal 3-6 days

Partial Thickness (Dermal)

Epidermis + Dermis

Superficial: heal 10-21 days, Uniformly pink, moist & painful,

scarring minimal if at all & function intact

Deep: heal 3-8 weeks, Dry & white, not painful d/t nerves

burned away, person will be severely scarred & lose fxn

Full Thickness

Epidermis + entire dermis, sometimes into fat

Cannot heal on own

Needs grafting to heal


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Capillary Leak

Total Burn < 20% BSA = localized

Total Burn > 20% BSA = systemic Ineffective Perfusion, Fluid

Volume Decrease, Ineffective Cardiac Output

Leak seals in 12-24 hours, fluid re-mobilization (migration from

interstitium back into vasculature) starts at about 24 hours, then 2-

3 days after, you enter the diuretic stage where the fluid is being

expelled.

Initially hyponatremic & hyperkalemic, later on hyponatremic &

hypokalemic

Fluid Resuscitation

Parkland formula: 3-4 ml/kg/% TBSA burned

total volume in first 8 hours

total volume over next 16 hours

Lactated Ringers has a little extra water & dont need to

give a maintenance fluid on top of that for ongoing hydration

needs.

Ongoing fluid resuscitation w/goal of urine output > 30 ml/hr


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Persistent massive fluid needs -> plasmapheresis being used to

modulate the inflammatory response

Calculating Fluid Administration (KNOW THIS!!! Per Kyla)

For Ms G: 50 kg; 65% burns; 3 ml/kg/% TBSA

3 ml/kg = 150 ml/%

150 x 65 = 9,750 ml

1st

8 hours = of total = 4875 @ 610 ml/hr

Next 16 hours = 4875 @ 305 ml/hr

8 hours starts from the time of the burn if pt got 2L fluid with

paramedics, for example, we dont count this in our equation.

Whether they got fluid or not, just do our calculation &

administration anyway

Systemic Effects r/t Capillary Leak (will cover in further detail when we

talk about sepsis & shock) see slide with list of symptoms


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ABCs Escharotomy sometimes needed since circumferential aschar

on trunk can compress lungs, inhibit ventilation. Also happens on

extremities & compresses circulation (note that escharotomy is not done

through fascia)

Burn Dressings

Goal: keep clean, moist, prevent infection

Note: cold water on burn only helps in 1st

degree type burns at

home, can contribute to hypothermia for more serious burns.

Wound coverings

Antimicrobial creams (silver sulfadiazene silver has

antimicrobial properties & also keeps moist)

Light wraping of gauze to keep cream in place

Wet dsg when wound is healing & not infected

We dont use wet-to-dry b/c v painful with these pts & that

level of debridement not usually needed

Wound treatments usually once or twice a day & this pt is at a

specialty center for burns

Nursing Concerns for these patients with big burn dressings

Pain pre-medicate, sometimes even with propofol


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Infection odor, purulence, exudate, edges of burn start to

look inflamed & red, graft will slough off if infectious process

is happening

Burns on her R arm from hot water best tx for this burn?

Cool the burn w/moist sterile compress then cover w/dry sterile

dressing & administer tetanus

Skin Grafting

Graft care

Ensure Adherence

May need wound vac

Can be homo or hetero graft some are human some are

pigs, or an auto graft self donation of skin graft pt can

keep donating from self, skin put through a mesher creating

honeycomb appearance.

Must be immobilized in that area until skin graft has taken

Acticoat helps skin heal (LOOKUP)

Nursing Care of the Burn Pt


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Alteration in comfort

RTC & PRN meds

Premedicate for wound care or other treatments

Risk for impaired wound healing r/t edema

Elevate

Soft wraps may be used to decrease swelling

Risk for altered nutrition

Start PO diet or tube feeds on admission as stress ulcer

prophy and high metabolic needs d/t injury. (Unless there is

some type of major indication)

Would monitor blood glucose as well & would keep glucose

out of fluids for 1st 24 hrs.

Risk for infection

Dressings as ordered

Environment

Massive burns may require tropicana room

Occupational/Physical Therapy from the very beginning, unless a

skin graft needs to adhere or some other contra-indication.

Maintain mobility & fxn

Prevent contractures


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N144 MSK Burns Abuse Lecture