Burns Fluid

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Burns Fluid Electrolytes

• Nursing 297
• Margaret Wilson MSN, Ed.D. RN

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Nursing 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.

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Mechanism/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

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Mechanism/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

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Mechanism/Type Chemical Burn
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Mechanism/TypeElectrical Burn

• - direct contact with electrical current
•                   entry exit wounds

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Burns Assessment/Physiology/ Classification

• Based on
• Depth/Degree of injury,
• Percent of body surface areas involved,
• Location of the burn,
• Association with other injuries.

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Burns Physiology/Classifica
tion Depth of Burn Assessment

• Epidermal destruction epidermis only
•      reddened,
•      blanches to pressure,
•      no blisters
•      painful
•      healing 3-5 days
•      no scarring

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Burns 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

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Burns 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

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Superficial Burn
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Burns 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

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Burns 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
•  

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Burns 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

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Deep Burn
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Burns 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

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Burns 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

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Burn 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

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Burn Assessment Lund Browder Chart
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Burn 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

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Hospitalization 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
  
•  

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Mortality in Burns

•          gt65 body surface area (BSA)
•          associated smoke inhalation
•          infection
• gt20 BSA with shock and other complications/relate
  d sequelae

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Collaborative 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
•  

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Collaborative 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
•  

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Collaborative 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

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Collaborative 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

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Collaborative 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
•  

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Collaborative 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.

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Nursing 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?

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Nursing 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

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Nursing 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

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Nursing 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

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Evaluation 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