Burns
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Burns. Linda Copenhaver. Introduction. Incidence of Burns ½ million seek medical care annually Approximately 40K are hospitalized Where do most burn trauma injuries occur? Bonus' Site - KitchenOilFire.wmv. Types of Burn Injury. Thermal Chemical Electrical Radiation.

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Burns

Burns

Linda Copenhaver


Introduction

Introduction

  • Incidence of Burns

    • ½ million seek medical care annually

    • Approximately 40K are hospitalized

    • Where do most burn trauma injuries occur?

    • Bonus' Site - KitchenOilFire.wmv


Types of burn injury

Types of Burn Injury

  • Thermal

  • Chemical

  • Electrical

  • Radiation


Thermal burns most common

Thermal Burns( Most Common)

  • Caused by flame, flash, scald, or contact burns

    • STOP & DROP

    • Roll to shut off O2 supply to fire

    • Flush or immerse in cold water

    • DO NOT use ICE on deep burns, just localized, superficial burns


Thermal burns cont

Thermal Burns (cont)

  • Cover patient with a clean cover

  • Do NOT pull off clothing; instead cut off clothing if possible…WHY?

  • Keep NPO and transport


Burns

  • Chemical Burns

    • Remove person from contact with agent

    • Flush with water continuously

    • Remove affected clothing if possible


Burns

  • Electrical burns

    • Coagulation necrosis

    • Severity depends on voltage, amount of resistance, time,

      and current

      pathways.


Electrical burn back

Electrical Burn–Back

Fig. 25-2 B


Burns

  • Frequently only entry (yellow-white) and exit (blow out) wounds are visible

  • Extensive tissue damage is masked

  • How can we evaluate “masked tissue damage”???


Electrical burns cont

Electrical Burns (cont)

  • Patient at risk for arrhythmias due to _____, metabolic acidosis due to _____, and acute tubular necrosis due to ______.

  • Current can be so strong to

    fracture long bones and cause respiratory muscles to contract


Interventions for electrical burns

Interventions for Electrical Burns

  • Turn off source of electricity if possible

  • Remove current with dry piece of wood

  • Initiate CPR and Transport


Cross section of skin

Cross Section of Skin

Fig. 25-3


Depth of burns

Depth of Burns

Superficial Partial Thickness Burn (1st

degree)

Epidermis involved

Sunburn, UV light, mild radiation,

Pink to red

Slight edema

Mild pain


Depth of burns1

Depth of Burns

  • Deep Partial Thickness (2nd)

    • Epidermis and some of dermis, is painful, red, blisters


Depth of burns2

Depth of Burns

  • Deep Partial Thickness (2nd)

    • Epidermis and Dermis

    • Very Painful, edema, pale

    • Moist or dry

    • Blisters


Depth of burns cont

Depth of Burns (cont)

  • Full Thickness Burns (3rd)

    • Epidermis, Dermis, and Subcutaneous tissue burned

    • Nerve endings destroyed

    • Little or no pain


Depth of burns cont1

Depth of Burns (cont)

  • Full thickness (4th degree)

    • Involves past the 3 layers down to the bone and/or organs


Rule of nines chart quick easy

Rule of Nines Chart; quick & easy

Fig. 25-4 B


Lund browder chart more accurate

Lund-Browder Chart; More accurate

Fig. 25-4 A


Burn unit referral criteria

Burn Unit Referral Criteria

  • Deep Partial Thickness burns > 10% TBSA

  • Burns that involve the face, hands, feet, genitalia, perineum, or major joints

  • Full thickness burns in any age group

  • Electrical burns, including lighting

  • Inhalation burns requiring intubation

  • Chemical burns that involve deep and extensive TBSA burned


Survival prediction

Survival Prediction

  • Depth of Burns

  • Extent of Burns

  • Location of Burns

  • Age of Client

  • Risk Factors

  • Major vs Minor Burns


Medical nursing management of burns

Medical/Nursing Management of Burns

  • I. Emergent Phase

    • Period of time from onset of burns to the beginning of fluid remobilization

    • Usually lasts 24-48 hours


Emergent phase cont

Emergent Phase (cont)

  • Also called FLUID ACCUMULATION PHASE

  • The greatest initial threat to a major burn victim is hypovolemic shock

  • Let’s do the Patho on p. 479 Lewis…this is a DING DING!


Some questions

Some Questions…..

  • The nurse knows that in a patient who has full thickness burns, that the burns must involve the:

    a) Muscle

    b) Dermis

    c) Tendons

    d) Bone


Burns

A 40 year old male sustains burns to his anterior torso following an explosion of a fuel tank. The burned area is brown and leather like. The client does not c/o pain. The nurse should conclude that the client has burns that are:

  • a) superficial partial thickness

  • b) moderate partial thickness

  • c) deep partial thickness

  • d) full thickness


What are the priorities in this patient

What are the Priorities in this patient???

  • Is this patient a candidate for a major burn center?


Nursing care during emergent phase

Nursing Care During Emergent Phase

  • Impaired Gas Exchange r/t tissue hypoxia secondary to carbon monoxide poisoning

  • Note: CO poisoning is the MOST immediate cause of death from fire.


Signs symptoms of carbon monoxide poisoning

Signs & Symptoms of Carbon Monoxide Poisoning

  • Edema of Airway

  • Hoarseness

  • Dysphagia

  • Stridor

  • Copius Secretions usually black tinged

  • Skin will appear cherry red


Cherry red skin appearance

Cherry red skin appearance


Interventions for co poisoning

Interventions for CO Poisoning:

  • Assess for S&S CO poisoning (mild to severe)

  • Humidified O2 100% via face mask

  • High Fowler’s Position

  • TCDB q 1 hour

  • Intubation & Ventilation

  • Bronchodilators for bronchospasm

  • One other thing…..does anyone know???


Nursing care during emergent phase cont

Nursing Care during Emergent Phase (cont)

  • Impaired Gas Exchange r/t mucosal edema throughout respiratory tract secondary to smoke inhalation, hot air, chemical gases


Interventions

Interventions:

  • Early intubation to prevent trach placement

  • Ventilation

  • Humidified O2 100%

  • ABG’s

  • Bronchodilators

  • CXR’s


Burns

  • What do you assess for here???


Question

Question:

  • A client has sustained deep partial thickness burns to the anterior trunk and the anterior aspect of both arms. The nurse should expect the client’s immediate care would be conducted:

    • a) on an outpatient basis

    • b) in a home health setting

    • c) on an inpatient surgical unit

    • d) in a burn unit


Questions to ask burn victims

Questions to Ask Burn Victims

  • Were you in an enclosed space?

  • Were you standing up?

  • Was it a flame and chemical fire?

  • Are you having difficulty breathing?


What are your 1 priorities in this patient

What are your #1 priorities in this patient?

Patient #1Patient #2


Emergent phase cont1

Emergent Phase (cont)

  • Ineffective Breathing pattern r/t constriction of chest/trachea secondary to the effects of full thickness burns.

    • Assess for signs of constriction

    • Escharotomies with circumferential burns of chest


Escharotomy of chest and arm

Escharotomy of chest and arm

  • What is the pathophysiology here?


Emergent phase cont2

Emergent Phase (cont)

  • Fluid Volume Deficit (intravascular) r/t massive fluid shift to interstitial spaces

    • Assess fluid needs:

      • Brooke Formula

      • Evans Formula


Burns

  • Parkland Baxter Formula

  • Most widely used

    • Formula

    • LR 4ml X kg body weight X TBSA % burned

      • ½ total amount given 1st 8 hours

      • ¼ total amount given next 8 hours

      • ¼ total amount given next 8 hours


Okay nurses let s calculate

Okay Nurses Let’s Calculate

  • What would the fluid replacement be for a patient who weighed 60kg and had 30% TBSA burned???

  • 1st 8 hours= _____ or ____ml/hr

  • 2nd 8 hours= _____ or _____ml/hr

  • 3rd 8 hours= ______ or _____ml/hr


Burns

  • Crystalloids used such as LR, 0.9NS, D5NS

  • Colloids (albumin, dextran, FFP) used to expand plasma.

  • Colloids not given until after capillary permeability decreases and returns to normal…..WHY?


Burns

  • Insert foley catheter to monitor output. What should urine output be in an adult???

  • Frequent vital signs

    • SBP>100

    • Pulse<100

    • RR 16-20


Emergent phase cont3

Emergent Phase (cont)

  • Monitor Electrolytes and Hematocrit; tells you about fluid shift.

    • What should Hct be doing as time progresses???


Burns

Using the Parkland formula, a client who has full and deep partial thickness burns to 30% of his body is to receive 6000ml of fluid over the next 24 hours. You would administer:

  • 1/3, 1/3 and 1/3 during each 8 hour period

  • 1/2, 1/4, and 1/4 during each 8 hour period

  • 1/4, 1/4, 1/4 and 1/4 during each 6 hour period

  • 1/8, 1/8, 1/4, and 1/2 during each 6 hour period


Emergent phase cont4

Emergent Phase (cont)

  • Potential for Infection r/t loss of skin and micro invasion

    • Meticulous hand washing

    • Sterile technique during dressing changes & wound care

    • Hair near burned areas shaved


Burns

  • Potential for Infection r/t loss of skin and micro invasion (cont)

    • Blisters popped or not???

    • Tetanus Toxoid I.M. given to all major burn victims to fight

      anaerobic contamination of burn wound


Burns

  • Hydrotherapy in cart (water is heated to approximately 104 degrees)

  • < 30 minutes to prevent _____


Hydrotherapy cart

Hydrotherapy Cart

  • What does hydrotherapy accomplish?


Wound care

Wound Care

  • Open Method

  • Apply topical chemotherapy


Topical meds antimicrobials

Topical Meds/Antimicrobials

  • Silvadene cream

  • Silver Nitrate or silver impregnated dressings such as Silverlon or Acticoat

  • Sulfamylon cream


Application of silver sulfadiazene to moistened gauze

Application of Silver Sulfadiazene to Moistened Gauze

Fig. 25-10


Wound care cont

Wound Care (cont)

  • Closed Method

    • Apply topical chemo and wrap with gauze, fluffs, kerlix

    • Assess for

      constriction;

      circulation

      checks


Emergent phase cont5

Emergent Phase (cont)

  • Elevate burned arms on pillows

  • Give pain meds 30 minutes

    prior to treatments


Emergent phase cont6

Emergent Phase (cont)

  • Alteration in body temp (hypothermia) r/t loss of skin

    • Set thermostats at warm temp in room (~85 degrees)


Emergent phase cont7

Emergent Phase (cont)

  • Potential for injury r/t effects of stress response:

    • Stress diabetes What is the patho here???

    • Curling’s ulcer (associated with burn trauma patients)

      • Gastroduodenal ulcer caused by increased gastric acid secretion


Emergent phase cont8

Emergent Phase (cont)

  • Potential for injury r/t effects of stress response:

    • Paralytic ileus (stress related)

      • NPO, NG tube to suction

    • Delirium (psychological stress)


Emergent phase cont9

Emergent Phase (cont)

  • Compartment syndrome r/t the effects circumferential burns

    Circulation is impaired

    Edema formation

    Occluded blood supply

    Ischemia

    Necrosis

    Gangrene


Emergent phase cont10

Emergent Phase (cont)

  • What is the treatment?

    • Escharotomy


Emergent phase cont11

Emergent Phase (cont)

  • Renal Failure

    • Hypovolemia (Why?)

    • blood flow to kidneys

    • Renal ischemia

    • ARF may develop


Emergent phase cont12

Emergent Phase (cont)

  • Renal Failure

    • Full thickness & electrical burns

    • Myoglobin from muscle cells released

    • Hgb (from RBCs breakdown) released into bloodstream

    • Blocks renal tubules


Emergent phase cont13

Emergent Phase (cont)

  • What is the treatment for these 2 renal problems????


Emergent phase cont14

Emergent Phase (cont)

  • Cardiac Function

    • Arrhythmias due to electrolyte imbalance or electrical burns

    • Hypovolemic shock due vascular bed depletion


Burns

  • Summary of Emergent Phase:


Ii acute phase weeks to months

II. Acute Phase (weeks to months)

  • Begins after 48-72 hours

  • Fluid begins to shift interstitial spaces back into bloodstream or intravascular space

  • Diuresis occurs

  • Ends when TBSA burned is <20% by grafting or wound healing


Nursing care during acute phase

Nursing Care During Acute Phase

  • Skin/systemic infection r/t

    • Loss of normal skin

    • Formation of eschar

    • Suppression of immune system

    • Metabolic/hormonal alterations


Acute phase

Acute Phase

  • Interventions for Skin/Systemic Infection:

    • Hydrotherapy cart shower to debride

    • Open/Closed dressing changes

    • Topical antimicrobials

    • Weekly cultures

    • Systemic antibiotics


Acute phase cont

Acute Phase (cont)

  • Rules for Treating Infection in Burn Patients:

    • Rule #1---no certain protocol

    • Rule #2---no matter how aseptic the environment, microorganisms are present

    • Rule #3---first the bug then the drug


Acute phase cont1

Acute Phase (cont)

  • Excision & Grafting

    • Removal of necrotic tissue

    • Eschar is removed until viable tissue is reached


Operative debridement

Operative Debridement


Burns

The RN just received report on the burn unit. Which client requires the most immediate assessment or intervention?

  • a) 22 yo old admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left

  • b) 34 yo who returned from skin graft surgery 3 hours ago and is c/o 8 out of 10

  • c) 45 yo with deep partial thickness leg burns who has temp of 102.6 and a bp of 98/46

  • d) 57 yo who was admitted with electrical burns 24 hours ago and has K+ level of 5.6mEq/L


Acute phase cont2

Acute Phase (cont)

  • Bleeding problem may be managed by debridement and surgical excision of the eschar one day and grafting to that site the next day.

  • Topical epinephrine or thrombin is applied to decrease bleeding from that area


Acute phase cont3

Acute Phase (cont)

  • Reasons for Grafting (priorities)

    • Survival

    • Function

    • Cosmetic

  • Synthetic Grafts

    • BIOBRANE


Types of grafts

Types of Grafts

  • Autograft or Autologous

    • self

  • Heterograft

    • Different species

      • Pig, bovine

  • Homograft

    • Cadaver

  • Which are temporary vs permanent?


New advanced grafts

New Advanced Grafts

  • Cultured Epithelial Autograft (CEA)

    • Patient’s own skin cells grown in culture dish—Permanent

      Latest in Skin Grafting--More options for Permanent Grafts


New advanced grafts1

New Advanced Grafts

Integra

  • Bovine collagen and glycosaminoglycan bonded to silicone membrane-Permanent

    AlloDerm

  • Acellular dermal matrix derived from donated human skin-Permanent


Acute phase cont4

Acute Phase (cont)

  • GRAFTING


Acute phase cont5

Acute Phase (cont)

  • GRAFTING


Dermatome harvesting donor skin from thigh

Dermatome-harvesting donor skin from thigh


Acute phase cont6

Acute Phase (cont)

  • For graft to SURVIVE and be effective:

    • Recipient bed must have adequate blood supply

    • Graft must be in close contact with recipient bed

    • Graft must be firmly fixed or immobile

    • Free from infection


Acute phase cont7

Acute Phase (cont)

  • Can you describe this???


Acute phase cont8

Acute Phase (cont)

  • Potential for fluid volume excess r/t fluid shift from interstitial back to intravascular space

    • Daily weights

    • Monitor lab values-Which ones?

    • Auscultate lungs

    • Fluids as ordered

    • Avoid free water-dilutional hyponatremia


Acute phase cont9

Acute Phase (cont)

  • Alteration in Nutrition r/t hypermetabolism

    • Goals are to minimize energy demands and to..

    • Provide adequate calories to promote wound healing


Acute phase cont10

Acute Phase (cont)

  • Interventions for altered nutrition:

    • Monitor bowel sounds

    • High Protein High CHO

    • Assess food preferences

    • Daily calorie count

    • TPN as ordered


Acute phase cont11

Acute Phase (cont)

  • Ineffective Coping r/t long rehab process with multiple surgeries and change in lifestyle/social isolation

    • Include family in plan of care

    • Assess client’s readiness to talk

    • Allow client to work through grief process

    • Give honest, accurate information


Burns

A client with deep partial and full thickness TBSA burned is 28% is receiving hydrotherapy. The nurse should assess for which of the following complications?

  • a) hypernatremia

  • b) dehydration

  • c) edema

  • d) hypothermia


Acute phase cont12

Acute Phase (cont)

  • Self-care Deficit r/t restricted movement/contractures/muscle atrophy


Interventions1

Interventions

  • Assist with positioning

  • ROM exercises

  • Support O.T. & P.T. efforts

  • Always maintain eye contact with client


Iii rehabilitation phase

III. Rehabilitation Phase

  • From wound closure to optimal level of physical and psychosocial adjustment

    • Potential for impaired home maintenance/integration back into social and work environment

      • Discuss grief process, self-concept, resocialization process

      • Sexuality issues, will I be a productive person? Will I be a good parent/partner?


Rehabilitation phase

Rehabilitation Phase

  • Instruct client on skin care:

    • Skin will itch, be dry, have a tight feeling

    • Use Vaseline Intensive Care ES lotion, mild soaps

    • Use Benadryl for itching

    • Avoid direct sunlight (will cause hyperpigmentation)


Rehabilitation phase1

Rehabilitation Phase

  • Instruct client on skin care:

    • Skin may be hypo or hyper sensitive to cold/heat/touch

    • Diet (high protein, vitamins)

    • Exercise to prevent contractures

    • Instruct client on S & S of infection


Rehabilitation phase2

Rehabilitation Phase

  • Instruct client to wear JoBST pressure garment up to 1 year


Rehabilitation phase3

Rehabilitation Phase

  • Instruct client on skin care:

    • Need to wear Jobst to prevent keloid formation


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