Clients with burns

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Clients with burns

• Factors associated with burns
• Age
• Young and elderly
• Careless smoking
• Alcohol and drugs
• Disabilities
• Occupations

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Types of burns

• Thermal
• Chemical
• Electrical
• Radiation

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Thermal burns

• Results from
• Dry heat
• Flame
• Moist heat
• Steam or hot liquids
• Most common type of burn

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Chemical burns

• Direct skin contact with acid or alkaline agents
• Alkali burns are deeper
• What are some sources of chemical burns?

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Electrical burns

• Severity depends on the type and duration of
  current and amount of voltage
• Destructive process
• Hard to assess
• Destructive process is concealed and persists for
  weeks
• Travels along path of least resistance
• Muscles, bones, nerves
• Impaired blood flow causes necrosis of tissues
• Can get gangrene in the wound

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Radiation burns

• Often from a sunburn
• Radiation treatments for cancer
• Functions of the skin are left intact

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Depth of burns

• Superficial First degree
• Involvement of only the epidermal layer
• Causes
• Sunburn
• Ultraviolet light
• Minor flash injuries
• Mild radiation burns

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• Appearance of burn
• Skin may be pink to red
• Slight edema
• Mildly painful
• Treatment
• Mild analgesia, water soluble lotions
• These burns heal in 3-5 days

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Partial thickness burns second degree

• Superficial partial thickness or deep partial
  thickness
• Depends on the depth of the burn through the
  dermis
• Causes
• Superficial
• Flash flame, dilute chemical agents, hot surface
• Deep
• Hot liquids, flash or direct flame, radiant
  energy, chemical agents

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• Appearance of burns
• Blisters
• Severe pain to air heat
• Treatment
• Analgesics, grafting may be necessary
• Burns heal in 21-28 days

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Full thickness burns third degree

• All layers of the skin, may extend into
  subcutaneous fat, muscle, bone
• Causes
• Prolonged contact with flames, steam, chemicals,
  high voltage electrical current

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• Appearance of burns
• Pale, waxy, yellow, brown, mottled, charred,
  nonblanching red
• No sensation of pain or light touch
• Treatment
• Skin grafting

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Extent of burn

• Total body surface area (TBSA)
• Extent of burn is expressed as a percentage of
  the TBSA
• Rule of 9s
• Rapid method of estimation
• Body is divided into 5 areas
• Head, trunk, arms, legs and perineum
• Percentages that total a sum of nines is assigned

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Example

• Client has burns to anterior trunk and right
  anterior leg
• Anterior trunk 18
• Right ant. Leg 9
• Total 27 of total body surface

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• American Burn Association
• Uses depth and extent of burn to classify them
• Minor
• Moderate
• Major
• When there are burns to the head, hands, feet,
  perineum, and joints
• All inhalation injuries
• Electrical injuries
• Burns covering large body areas
• Injuries to high risk patients

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What happens before the client comes to the
hospital?
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Pre hospital care

• Stop the burning process
• Stabilize the client
• CPR
• Initiate fluid replacement
• Cover client
• Prevent heat loss

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Priorities at the scene

• Respiratory status
• Ventilation
• Burns of face, neck, anterior chest require
  prophylactic intubation
• Watch for hoarseness, dyspnea, tachypnea stridor,
  cyanosis, wheezing, crackles

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• Hemodynamic status
• Start large bore IV at the scene
• Burns of more than 20 require fluid replacement
• Keep patient warm
• CPR

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Emergency department care

• Take history of burn
• Time
• Cause
• Early tx
• Past medical hx
• Age
• Medications
• Body weight

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• Classify the burn
• Extent
• Depth
• Estimation of burn extent
• Rule of 9s

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When should a patient be transferred to a burn
unit?

• Burn covering 10 of body surface lt 10y/o
  gt50y/o
• Burn covering 20 of body surface 10-50y/o
• Burn involving hands, face, feet, eyes ears of
  perineum
• Inhalation injury
• Electrical injury
• Burn with extenuating circumstances

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Stages of burn injury

• 3 stages
• Emergent/resuscitative stage
• Acute stage
• Rehabilitative stage

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Emergent stage

• 1st 48 72 hours
• Estimate the extent of the burn
• First aid and wound care
• Fluid resuscitation
• Determine whether to transfer to burn unit
• Assessment of other injuries

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Acute stage

• This stage begins with diuresis and lasts until
  all full thickness wounds are covered with skin
  grafts.
• Parental and enteral nutrition is began
• Aggressive tx to prevent infection
• Pain management

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Rehabilitative stage

• This stage begins with wound closure
• Focus on client returning to a useful place in
  society
• Restoring joint function
• Emotional support

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• Care in all three stages is done through a
  multidisciplinary approach.
• Nurses
• Physicians
• PT
• Social workers
• OT
• RD

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Body Systems and Burns

• All body systems are affected by major burns

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Cardiovascular

• Cardiovascular system goes into a state called
  burn shock
• Generally lasts 24 hours
• Fluid volume shift from intracellular to
  interstitial spaces
• Massive shift and patient becomes unstable

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Why is there a shift?

• Loss of cell wall integrity at the burn site
• Causes fluid to leak out
• Result??
• Decrease in fluid volume
• Decreased cardiac output

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• Edema of tissue
• Impairs peripheral circulation
• Can lead to ischemia and necrosis of tissues
• Decrease in B/P
• Vasoconstriction
• Increased viscosity of blood
• K leaves intracellular space
• Can lead to dysrhythmias

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• When does burn shock end?
• When the fluid is reabsorbed in to the
  intravascular compartment
• When this occurs
• Increased cardiac output
• Increased B/P
• Improved urinary output

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• Patients need close monitoring
• Particular problem for those with pre-existing
  cardiac conditions and the elderly

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Respiratory System

• Major problem is inhalation injuries
• Carbon monoxide
• Toxic gases
• Smoke
• Heat

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• Degree of injury depends on
• Duration of exposure
• Composition of the product
• Solubility in water
• Size of particulate of aerosol droplet

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• Injury includes
• Inflammation at site
• Destruction of affected cells
• Interstitial pulmonary edema
• Surfactant inactivated

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Immune System

• Impaired immune system due to capillary leak
• Impairs cell mediated and humoral immune systems
• Humoral system
• Serum levels of immunoglobulins are diminished
• Cell mediated
• Decreased T-cell counts
• Results in acquired immune deficiency
• Increased Risk for Infection

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Integumentary System

• Burns result in impaired normal physiologic
  functions of the skin
• Thermoregulation
• Synthesizer of Vitamin D
• Excretory organ
• Sensory organ
• Barrier against infection

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Gastrointestinal System

• Hyperacidity causes erosion of the gastric and
  duodenal linings
• Curlings ulcer
• S/S
• Abdominal pain
• Acidic gastric pH levels
• Hematemesis
• Melanotic stool
• Paralytic ileus
• S/S
• Gastric distention, nausea, vomitting absence of
  BS

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Urinary System

• Massive fluid losses initially can cause
• Dehydration
• Hemoconcentration
• Oliguria
• May result in renal failure
• Concern with this system if perineum has been
  burned?

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Metabolism

• 2 phases
• Ebb phase
• 1st 3 days
• Decreased O2 consumption
• Fluid imbalance
• Shock
• Inadequate circulating volume
• Flow phase
• Occurs after adequate resuscitation has been
  accomplished
• Increases cellular activity
• BMR (basal metabolic rate) can double the normal
  level
• Body weight and heat drop
• Will continue until after the wound is closed

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Treatment

• Fluid resuscitation begins ASAP
• Can include fluids, blood and blood products

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• Considerations when replacing fluids
• Patients weight
• Hours post burn
• Urine output (30-50 ml/hr)
• Extent of burn
• Inhalation injury
• Electrical injury
• Degree of burn
• Any delayed starts in fluid resuscitation measures

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Fluids of choice

• 1st 24 hours
• Lactated ringers
• Closely approximates bodys extracellular fluid
• 2nd 24 hours
• LR discontinued
• Colloid started
• Albumin
• Plasmanate
• Dextrose in water solution

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Invasive lines

• May need arterial line
• Pulmonary artery catheter

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Other considerations

• Ventilatory management
• Baseline studies
• Important others
• Positioning
• TCDB
• Intubation if needed

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Labs Diagnostics

• Labs
• CBC
• Electrolytes
• UA
• ABGs
• Pulse oximetry
• CXR
• EKG

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Pharmacology

• Pain
• Narcotics
• Antimicrobial agents
• Topically
• 0.5 silver nitrate
• 1 silversulfadiazine
• 10 mafenide acetate
• Systemically
• Indicated with infections and pre and post
  operatively with excision and grafting

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• Tetanus
• Gastric hyperacidity prevention
• NG with hourly gastric pH levels. Keep above 5
• H2 blockers such as Zantac

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Nutritional Support

• Enteral feeding starts within 24-48 hours post
  burn
• Parenteral nutrition
• Given if EF contraindicated
• Curlings ulcer
• Bowel obstruction
• Feeding intolerance
• Pancreatitis
• Septic ileus
• TPN through central line

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Wound management

• Hydrotherapy
• Cleanse with mild soap
• Pre-medicate patient
• Debridement
• Removal of dead tissue
• Can be done
• Mechanically
• Enzymatically
• Surgically

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Dressings

• Biological dressing
• Any temporary material that rapidly adheres to
  wound bed
• Prepare wound for permanent grafting
• Easy to apply and remove
• Homograft
• Human skin harvested from cadavers
• Expensive and hard to get
• Rejected within 14-21 days
• Heterograft
• Obtained from animals
• Needs to be changed frequently
• High risk of infection
• Synthetic materials

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Surgical Management

• Debridement
• Escharotomy
• Hard crust that forms over wound
• Grafting

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Preventing Scars, Keloids and Contractures

• Positioning
• Splinting
• Exercise
• Support garments

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Nursing Diagnosis

• Impaired skin integrity
• Fluid volume deficit
• Risk for infection
• Altered nutrition less than body requirements
• Body image disturbance
• Impaired physical mobiltiy
• Altered tissue perfusion