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

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


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)

  • Cover patient with a clean cover

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

  • Keep NPO and transport


  • Chemical Burns

    • Remove person from contact with agent

    • Flush with water continuously

    • Remove affected clothing if possible


  • Electrical burns

    • Coagulation necrosis

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

      and current

      pathways.


Electrical Burn–Back

Fig. 25-2 B


  • 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)

  • 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

  • Turn off source of electricity if possible

  • Remove current with dry piece of wood

  • Initiate CPR and Transport


Cross Section of Skin

Fig. 25-3


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 Burns

  • Deep Partial Thickness (2nd)

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


Depth of Burns

  • Deep Partial Thickness (2nd)

    • Epidermis and Dermis

    • Very Painful, edema, pale

    • Moist or dry

    • Blisters


Depth of Burns (cont)

  • Full Thickness Burns (3rd)

    • Epidermis, Dermis, and Subcutaneous tissue burned

    • Nerve endings destroyed

    • Little or no pain


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

Fig. 25-4 B


Lund-Browder Chart; More accurate

Fig. 25-4 A


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

  • Depth of Burns

  • Extent of Burns

  • Location of Burns

  • Age of Client

  • Risk Factors

  • Major vs Minor 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)

  • 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…..

  • 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


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???

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


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

  • Edema of Airway

  • Hoarseness

  • Dysphagia

  • Stridor

  • Copius Secretions usually black tinged

  • Skin will appear cherry red


Cherry red skin appearance


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)

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


Interventions:

  • Early intubation to prevent trach placement

  • Ventilation

  • Humidified O2 100%

  • ABG’s

  • Bronchodilators

  • CXR’s


  • What do you assess for here???


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

  • 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?

Patient #1Patient #2


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

  • What is the pathophysiology here?


Emergent Phase (cont)

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

    • Assess fluid needs:

      • Brooke Formula

      • Evans Formula


  • 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

  • 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


  • 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?


  • 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 (cont)

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

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


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 (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


  • 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


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

  • < 30 minutes to prevent _____


Hydrotherapy Cart

  • What does hydrotherapy accomplish?


Wound Care

  • Open Method

  • Apply topical chemotherapy


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

Fig. 25-10


Wound Care (cont)

  • Closed Method

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

    • Assess for

      constriction;

      circulation

      checks


Emergent Phase (cont)

  • Elevate burned arms on pillows

  • Give pain meds 30 minutes

    prior to treatments


Emergent Phase (cont)

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

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


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 (cont)

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

    • Paralytic ileus (stress related)

      • NPO, NG tube to suction

    • Delirium (psychological stress)


Emergent Phase (cont)

  • Compartment syndrome r/t the effects circumferential burns

    Circulation is impaired

    Edema formation

    Occluded blood supply

    Ischemia

    Necrosis

    Gangrene


Emergent Phase (cont)

  • What is the treatment?

    • Escharotomy


Emergent Phase (cont)

  • Renal Failure

    • Hypovolemia (Why?)

    • blood flow to kidneys

    • Renal ischemia

    • ARF may develop


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 (cont)

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


Emergent Phase (cont)

  • Cardiac Function

    • Arrhythmias due to electrolyte imbalance or electrical burns

    • Hypovolemic shock due vascular bed depletion


  • Summary of Emergent Phase:


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

  • Skin/systemic infection r/t

    • Loss of normal skin

    • Formation of eschar

    • Suppression of immune system

    • Metabolic/hormonal alterations


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)

  • 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 (cont)

  • Excision & Grafting

    • Removal of necrotic tissue

    • Eschar is removed until viable tissue is reached


Operative Debridement


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 (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 (cont)

  • Reasons for Grafting (priorities)

    • Survival

    • Function

    • Cosmetic

  • Synthetic Grafts

    • BIOBRANE


Types of Grafts

  • Autograft or Autologous

    • self

  • Heterograft

    • Different species

      • Pig, bovine

  • Homograft

    • Cadaver

  • Which are temporary vs permanent?


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 Grafts

Integra

  • Bovine collagen and glycosaminoglycan bonded to silicone membrane-Permanent

    AlloDerm

  • Acellular dermal matrix derived from donated human skin-Permanent


Acute Phase (cont)

  • GRAFTING


Acute Phase (cont)

  • GRAFTING


Dermatome-harvesting donor skin from thigh


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 (cont)

  • Can you describe this???


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 (cont)

  • Alteration in Nutrition r/t hypermetabolism

    • Goals are to minimize energy demands and to..

    • Provide adequate calories to promote wound healing


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 (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


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 (cont)

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


Interventions

  • Assist with positioning

  • ROM exercises

  • Support O.T. & P.T. efforts

  • Always maintain eye contact with client


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

  • 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 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 Phase

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


Rehabilitation Phase

  • Instruct client on skin care:

    • Need to wear Jobst to prevent keloid formation


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