Management of Patients with Burn Injuries

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Management of Patients with Burn Injuries

• Janie Best, RN, MSN, ACNS-BC, ONC

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Objectives

• Relate principles of anatomy and physiology to
  the nursing care of individuals with burn
  injuries
• Integrate the nursing process as a framework in
  the management of patients with burn injuries
• Evaluate effectiveness of appropriate nursing
  interventions in achieving optimal outcomes of
  planned care for the adult with burn injuries

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Goals of Burn Care

• Prevention
• Institution of lifesaving measures for the
  severely burned person
• Prevention of disability and disfigurement
  through early, specialized, individualized
  treatment
• Rehabilitation through reconstructive surgery and
  rehabilitative programs

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At Risk Populations

• Young children
• Elderly highest mortality

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Gerontologic Considerations

• Reduced mobility
• Changes in vision
• Decreased sensation in feet and hands
• Predisposed to deep injury
• Thinning and loss of elasticity of skin
• Chronic illness decreases ability to respond to
  stressors

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Health Prevention

• Keep all matches and lighters away from children
• Do not leave children alone around fires
• Install and maintain smoke detectors
• Set water-heater temperature no higher than 120º
  F.
• Do not smoke in bed or fall asleep while smoking
• Use caution when cooking
• Keep a working fire extinguisher in the home

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Layers of the Skin
Brunner, 2008, Figure 55.1. anatomic structures
of the skin
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Assessment

• Cause of burn
• Amount of area involved
• Depth
• Severity

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Types (Causes) of Burn Injury

• Thermal
• Open flame, steam, hot liquids
• Chemical
• Acids, strong alkalis, organic compounds
• Electrical
• Direct or alternating current, lightning
• Radiation
• Radioactive agents

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Rules of 9s

• Estimates extent of burn injury
• Measures total body surface area (TBSA)
• Assigns percentages in multiples of 9 to major
  body surfaces

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Classification of Burns

• Superficial Partial Thickness
• Similar to 1st degree
• Skin pink to red
• Outer layers of skin damaged
• Painful
• Heals without grafting

www.virtualrheumatologycentre.com
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Classification of Burns

• Deep partial thickness
• Similar to 2nd degree
• Skin red to white
• Blisters
• Weeping surface
• Edema
• All epidermis and much of dermis damaged
• Painful
• Heals without grafting

www.regionshospital.com
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Classification of Burns

• Full thickness
• Similar to 3rd degree
• Charred appearance (black, brown, leathery)
• Waxy, white
• Edema
• All layers of skin destroyed
• Nerves, muscle tissue, and bone may be destroyed
• Grafting preferred

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Indicators of possible pulmonary damage

• History indicating that the burn occurred in an
  enclosed area
• Burns of the face or neck
• Singed nasal hair
• Hoarseness, voice change, dry cough, stridor,
  sooty sputum
• Sooty or bloody sputum
• Labored breathing or tachypnea (rapid breathing)
  and other signs of reduced oxygen levels
  (hypoxemia)
• Erythema and blistering of the oral or pharyngeal
  mucosa

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Burns to the Eyes
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Pre-hospital Care

• Stop the burning process
• Thermal smother stop, drop, and roll
• Chemical remove clothing and flush / irrigate
  skin / eyes
• Electrical shut off electrical current or
  separate person from source with a nonconducting
  implement (such as wooden broomstick)
• Radiation limit exposure

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Before transport to burn center

• Establish patent airway 100 humidified Oxygen.
• Adequate peripheral circulation is established in
  any burned extremity.
• A secure IV catheter is inserted
• lactated Ringer's solution infusing at the rate
  required to maintain a urine output of at least
  30 mL per hour.
• Indwelling urinary catheter
• Administer IV pain medication (Morphine)
• Wounds are covered with a clean, dry sheet
• Keep patient comfortably warm.

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Emergent / Resuscitative Phase

• First 24-48 hrs
• Fluid loss through open wound or extravasation
  into deeper tissues
• Hypovolemia
• Renal complications possible
• Hyperkalemia
• ? Pulse, ? Blood Pressure

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Intermediate / Acute Phase

• Begins 36-48 hrs after burn
• Decrease in peripheral edema
• Blood volume restored
• Diuresis if renal system is unimpaired
• Hypokalemia
• ? Blood pressure

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Interdisciplinary Care

• Emergent / resuscitative stage
• Emergency team (EMT, ED)
• Acute stage
• Burn team (ICU), Nutrition, Wound, Rehab,
  Psychosocial support
• Rehabilitative stage
• Social service team, Rehab, Community services

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Management of Fluid Loss Emergent stage

• Fluid resuscitation formula
• Lactated Ringers, plasma
• Adequate replacement if
• Urine output to be 30 ml 50 ml / hr
• Systolic B/P gt 100 mg Hg
• Pulse lt 110
• Hourly strict Intake and Output
• Clinical parameters important indicators of
  effectiveness of fluid resuscitation

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Management of Fluid Loss Intermediate stage

• Fluid resuscitation
• Packed RBCs
• Hourly strict Intake and Output
• Assess for fluid overload vs dehydration
• Weight, B/P, serum electrolytes

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Goals of Wound Management

• Control microbial colonization and prevent wound
  infection
• Prevent wound progression
• Achieve wound coverage as early as possible
• Promote function of healing skin

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Wound Treatment

• Surgical debridement
• Fasciectomy
• Escharotomy
• Autografting
• Allograft
• Xenograft

www.chw.edu.au
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Wound Care

• Avoid
• Cross-contamination of wounds
• Wrapping dressings too tightly around extremity
• Use
• Topicals
• Reduce the number of bacteria only
• Silver sulfadiazine (Silvadene)
• Slow release dressings such as Acticoat, Aquacel,
  Silversorb, Silverlon

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Nursing Considerations

• Goals
• Correct fluid and electrolyte imbalance
• Promote wound healing
• Support nutrition
• Control pain
• Prevent complications of immobility
• Support patient

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NCLEX Questions

• Which nursing intervention holds the highest
  priority of a patient with burns to her face and
  upper respiratory tract?
• A Elevate the head of the bed to at least 30º
• B Administer six liters of oxygen via nasal
• cannula
• C Medicate the patient prior to repositioning
• the patient in bed
• D Prevent moving the skin around the burn
• site

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NCLEX Questions

• Which nursing intervention holds the highest
  priority of a patient with burns to her face and
  upper respiratory tract?
• A Elevate the head of the bed to at least 30º
• B Administer six liters of oxygen via nasal
• cannula
• C Medicate the patient prior to repositioning
• the patient in bed
• D Prevent moving the skin around the burn
• site

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NCLEX Questions

• When teaching a community group about radiation
  burns, which statement best reflects the goals of
  treatment?
• A. Radiation burns are usually mild, and involve
  only the surface of the skin
• B. Severe radiation burns are usually caused by
• industrial accidents.
• C. Radiation burns are much less common than
• thermal burns.
• D. Promoting wound and body healing are the most
  
• important goals of treatment.

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NCLEX Questions

• When teaching a community group about radiation
  burns, which statement best reflects the goals of
  treatment?
• A. Radiation burns are usually mild, and involve
  only the surface of the skin
• B. Severe radiation burns are usually caused by
• industrial accidents.
• C. Radiation burns are much less common than
• thermal burns.
• D. Promoting wound and body healing are the most
  
• important goals of treatment.

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NCLEX Questions

• What is the highest priority for the nurse when
  caring for a patient who has just received an
  electrical burn?
• Disconnect the patient from the electrical
• source
• B. Ensure the patients have a cervical collar
• and be placed on a back board prior to
  care.
• C. Monitor for cardiac dysrhythmia.
• D. Patients may require changes in fluid
• resuscitation as compared to patients
  with
• other types of burns.

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NCLEX Questions

• What is the highest priority for the nurse when
  caring for a patient who has just received an
  electrical burn?
• A. Disconnect the patient from the electrical
• source
• B. Ensure the patients have a cervical collar
• and be placed on a back board prior to
  care.
• C. Monitor for cardiac dysrhythmia.
• D. Patients may require changes in fluid
• resuscitation as compared to patients
  with
• other types of burns.