Title: Burns Fluid
1Burns Fluid Electrolytes
- Nursing 297
- Margaret Wilson MSN, Ed.D. RN
2Nursing Care BURN INJURIES
- 1. Identify the mechanism of burn (TYPE)
injuries. - 2. Describe methods for determining
assessment/physiology/ classification of burns. - 3. Differentiate degrees of burn (1st- 4th)
versus epidermal/superficial, partial and full
thickness, deep burns. - 4. Determine nursing care based upon the systemic
pathological changes associated with burn injury
in the first 24 48 hours. - 5. Identify assessment, nursing diagnoses and
management of the burn victims airway, breathing
and circulation and wounds. - 6. Identify the Pain/Nutritional/Rehab
requirements for a burns patient.
3Mechanism/Burn Type
- Thermal - burning of tissue via direct contact
with a heat source hot water, flame - Zones of Injury
- 1. Zone of coagulation thrombosis,
vasoconstriction, necrosis and cell death - 2. Zone of stasis - low blood flow
- 3. Zone of hyperemia - inflammatory response
4Mechanism/Burn Type
- Chemical - tissue destruction via direct contact
chemical - oxidizing agent sodium hypo chloride
- reducing agent hydrochloric acid
- corrosives phosphorus
- protoplasmic poisons formic acid
- desiccants sulfuric acid
- vesicants mustard gas
- gasoline
5Mechanism/Type Chemical Burn
6Mechanism/TypeElectrical Burn
- - direct contact with electrical current
- entry exit wounds
7Burns Assessment/Physiology/ Classification
- Based on
- Depth/Degree of injury,
- Percent of body surface areas involved,
- Location of the burn,
- Association with other injuries.
8Burns Physiology/Classifica
tion Depth of Burn Assessment
- Epidermal destruction epidermis only
- reddened,
- blanches to pressure,
- no blisters
- painful
- healing 3-5 days
- no scarring
9Burns Physiology Classification Depth/Degree
of Injury
- First Degree superficial, epidermal damage
- erythematous painful due to intact nerve
endings - heal in 5-10 days
- pain resolves within 3 days
- no residual scarring
10Burns Physiology Classification Depth/Degree
of Injury
- Second Degree partial thickness, epidermis/
dermis - superficial burns moist, blister
- deeper burns - white and dry, blanch with
pressure, and have reduced pain - heal in 10-14 days
- can develop into third degree burns with
infection, edema, inflammation and ischemia - treatment varies with degree of involvement -
grafting is indicated for deep burns
11Superficial Burn
12Burns Physiology /
Classification Depth of Burn Assessment
- Partial Thickness
- Superficial destruction epidermis to upper dermis
- bright red to pale ivory, blistered or
weeping, blanches to pressure - sensitive to pain, pressure temperature
healing 14-21 days , no scarring
13Burns Physiology/Classifica
tion Depth of Burn Assessment
- Partial Thickness
- deep destruction epidermis to deep dermis
- mottled
- white waxy
- blistering
- diminished sensation to light pressure
- healing months-weeks/usually scarring
-
14Burns Physiology Classification Depth/Degree
of Injury
- Third Degree full-thickness, most severe of
burns - results in necrosis and avascular areas
- tough, waxy, brownish leathery surface with
eschar, numb to touch - grafting required
- usually have permanent impairment
15Deep Burn
16Burns Physiology Classification Depth/Degree
of Injury
- Fourth Degree
- full-thickness as well as adjacent structures
such as fat, fascia, muscle or bone - reconstructive surgery is indicated
-
- severe disfigurement is common
17Burns Physiology Classification Depth/Degree
of Injury
- Full - destruction to epidermis, dermis,
subcutaneous - dry,
- pearly/yellow-charred,
- does not blanch,
- leathery, inelastic
- minimal to no sensation of pain, healing
via secondary granulation/graft
18Burn Assessment
- Body Surface Area
- Rule of Nines
- adult 9 head 9 arms 18 legs 18 chest
18 back 1 perineum - child 18 head 9 arms 14 legs 18 chest
18 back
19Burn Assessment Lund Browder Chart
20Burn Assessment
- Location
- Important for assessing potential disability
- greatest risk with face, eyes, ears, feet,
perineum and hands - Upper extremities involved in 71 of burns, head
and neck 52
- Associated Injuries
- Smoke inhalation
- hoarseness, cough, singed nasal hairs, oral
burns, wheezing - Carbon monoxide poisoning
- Fractures
- Trauma
21Hospitalization in Major Burns
- gt10 surface area in children, elderly
- gt15 surface area in adults
- specific regions - respiratory tract,
face, neck, circumferential burns, hands,
feet, major joints, genitalia, electrical
burns, lightening burns - 3rd degree burns gt3 children, gt5 adults
-
22Mortality in Burns
- gt65 body surface area (BSA)
- associated smoke inhalation
- infection
- gt20 BSA with shock and other complications/relate
d sequelae
23Collaborative Nursing Medical Management
- Pathology of the First 24 hours
- Temperature loss hypothermia
- Plasma Protein Loss
- Hypovolemia/hemoglobin concentration
Tissue/blood destruction hypoxia - Release hemoglobin pigment/myoglobin
- GFR UO
- Tissue hypoxia and reduced renal function
metabolic acidosis - Platelet destruction of activation
clotting cascade via intrinsic/extrinsic pathway
DIC -
24Collaborative Nursing Medical Management
- Pathology of the Second 48 hours
- temperature
- 2. fluid mobilization to intravascular space
- 3. renal loss K
- 4 Fluid resuscitation Serum Na
- dilutional coagulopathy
-
25Collaborative Nursing Medical Management
- Wound Care
- tetanus toxoid gt 50 BSA burn
- and/or tetanus immunization
- chemical burns
- irrigate all burns, cover until initial
resuscitation complete - electrical burns
- AC current Tetany risk Vent Fib
- High energy check volts blunt injuries
26Collaborative Burn Management
- Primary Assessment Resuscitation
- Airway check risks event in an enclosed area,
singed eyebrows/nasal hair, hoarse voice,
stridor, wheeze, air entry/edema - Breathing check risks event in an enclosed
area evaluate for - CO2 poisoning
- high PaO2
- low SataO2
27Collaborative Burn Management
- Circulation Assessment Resuscitation
- Parkland Formula one of the most commonly
usedFirst 24 hours an isotonic solution (Ringers
Lactate)4mL/kg x TBSA - divide into 8 hour periods
- - first 50 in 8 hours
- - next 25 in 8 hours
- - final 25 in 8 hours
- urinary output should be 50-70mL/hr (1mL/kg) in
the first 24 hours -
28Collaborative Burn Management
- Circulation Cont Assessment Resuscitation
- Second 24 hours
- Colloid/plasma is delivered 0.5mL/kg x TBSA for
the next 8 hours. - At 32 hours
- 5 Dextrose nutritional replacement
- require serial measurement serum electrolytes,
urea, hematocit, blood albumin, urinary N.
29Nursing Diagnoses
- Altered Tissue Perfusion
- Fluid Electrolyte Imbalance
- Risk for Infection
- Altered Comfort Pain
- Altered Nutritional Less than Body Requirements
(more Calories needed) - Body Image Change Loss? Role?
30Nursing Care
- IV access (Multiple)
- Manage perfusion needs by parameters of CVP,
Urinary Output - Pain management
- once vital signs have stabilized, pain medication
should be used (ie morphine, or meperidine,
fentanyl, benzodiazepines as indicated ) - Morphine or Fentanyl Drip
31Nursing Care of Ulcer/Pain/Tetanus
- Curlings ulcer prophylaxis (Peptic Ulcer)
- An H2 blocker (cimetidine, ranitidine,famotidine)
start first 6 hours - antacids are no longer recommended - the patient
should be kept NPO - with burns gt 15 of BSA, an NG (OG) tube and
bladder catheter should be placed - Tetanus
- immunization if out of date
32Nursing Care of Burn Wounds
- Wound Care (Sterile Technique)
- Debridement
- Anti-microbial Application
- silver sulfadiazine (Silvadine)
- mafenide acetate (Sulfamylon)
- Closed dressing except face perineum
- Wound cover
- synthetic,biosynthetic, biological
- Graft
- Wound Allograft
- Split thickness skin graft
- full thickness graft
33Evaluation of Nursing Care
- ABCs Airway stridor
- Breathing use of accessory muscles, lung sounds
- Circulation CVPs, BP, Pulse-Ox
- Fluids Electrolytes/Renal
- Urinary output, labs, specific gravity,
osmalarity, myoglobin - Pain
- Infection (Gram Negative Sepsis)
- Nutrition
- Weight, ulcer Management