Burns

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Burns

• Linda Copenhaver

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Introduction

• Incidence of Burns
• 1 million seek medical care annually
• Approximately 100K are hospitalized, 70K require
  ICU
• stays

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Bonus' Site - KitchenOilFire.wmv
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Types of Burn Injury

• Thermal
• Chemical
• Electrical
• Radiation

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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

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Thermal Burns (cont)

• Cover patient with a clean cover
• Do NOT pull off clothing instead cut off
  clothing if possibleWHY?
• Keep NPO and transport

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• Chemical Burns
• Remove person from contact with agent
• Flush with water continuously
• Remove affected clothing if possible

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• Electrical burns
• Coagulation necrosis
• Severity depends on voltage, amount of
  resistance, time,
• and current
• pathways.

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• Frequently only entry (yellow-white) and exit
  (blow out) wounds are visible
• Extensive tissue damage is masked
• How can we evaluate masked tissue damage???

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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

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Interventions for Electrical Burns

• Turn off source of electricity if possible
• Remove current with dry piece of wood
• Initiate CPR and Transport

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Depth of Burns

• Superficial Partial Thickness Burn (1st
• degree)
• Epidermis involved
• Sunburn, UV light, mild radiation,
• Pink to red
• Slight edema
• Mild pain

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Depth of Burns

• Deep Partial Thickness (2nd)
• Epidermis and dermis, is painful, red, blisters

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Depth of Burns

• Deep Partial Thickness (2nd)
• Epidermis and Dermis
• Very Painful, edema, pale
• Moist or dry
• Blisters present

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Depth of Burns (cont)

• Full Thickness Burns (3rd)
• Epidermis, Dermis, and Subcutaneous tissue burned
• Nerve endings destroyed
• Little or no pain

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Depth of Burns (cont)

• Full thickness (4th degree)
• Involves past the 3 layers down to the bone
  and/or organs

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Extent of Burns

• Rule of Nines
• Easy to remember, quick method

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• Lund Browder
• More accurate, more time spent
• calculating TBSA burned

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Burn Unit Referral Criteria

• Deep Partial Thickness burnsgt10 TBSA
• Burns that involve the face, hands, feet,
  genitalia, perineum, or major joints
• Full thickness burns in any age group
• Electrical burns, including lightning
• Inhalation burns requiring intubation
• Chemical burns that involve deep and extensive
  TBSA burned

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Survival Prediction

• Depth of Burns
• Extent of Burns
• Location of Burns
• Age of Client
• Risk Factors
• Major vs Minor Burns

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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

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Emergent Phase (cont)

• Also called FLUID ACCUMULATION PHASE
• The greatest initial threat to a major burn
  victim is hypovolemic shock
• See outline for detailsthis is a DING DING!

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Burning Question..

• 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

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What are the Priorities in this patient???

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

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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.

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Signs Symptoms of Carbon Monoxide Poisoning

• Edema of Airway
• Hoarseness
• Dysphagia
• Stridor
• Copius Secretions usually black tinged
• Substernal Retractions

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Interventions for CO Poisoning

• Assess for SS CO poisoning (mild to severe)
• Humidified O2 100 via face mask
• High Fowlers Position
• TCDB q 1 hour
• Intubation Ventilation
• Bronchodilators for bronchospasm
• One other thing..does anyone know???

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Nursing Care during Emergent Phase (cont)

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

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Interventions

• Early intubation to prevent trach placement
• Ventilation
• Humidified O2 100
• ABGs (respiratory acidosis or alkalosis?)
• Bronchodilators
• Serial CXRs and fiberoptic bronchoscopy

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• What do you assess for here???

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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
  clients 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

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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?

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What are your 1 priorities in this patient?

• Patient 1 Patient 2

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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

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Escharotomy of chest and arm

• What is the pathophysiology here?

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Emergent Phase (cont)

• Fluid Volume Deficit (intravascular) r/t massive
  fluid shift to interstitial spaces
• Assess fluid needs
• Brooke Formula
• Evans Formula

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• Parkland Baxter Formula
• Most widely used
• Formula
• LR 4ml X Kg body weight X TBSA burned
• ½ that total amt. given 1st 8 hours
• ¼ that total amt. given each next 8 hours

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Okay Nurses Lets Calculate

• What would the fluid replacement be for patient
  who weighed 60kg and had 30 TBSA burned???
• 1st 8 hours _____or ____cc/hr
• 2nd 8 hours _____or ____cc/hr
• 3rd 8 hours _____or ____cc/hr

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• 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?

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• Insert foley catheter to monitor output. What
  should urine output be in an adult???
• Frequent vital signs
• SBPgt100
• Pulselt100
• RR 16-20

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Emergent Phase (cont)

• Assess Neuro status
• Neuro vital signs, WHY???
• Monitor Electrolytes and Hematocrit tells you
  about fluid shift.
• What should Hct be doing as time progresses???

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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

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• 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

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• Hydrotherapy in cart (water is heated to
  approximately 104 degrees)
• lt 30 minutes to prevent _____

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Hubbard Tank (old method)
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Hydrotherapy Cart

• What does hydrotherapy accomplish?

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Wound Care

• Open Method
• Apply topical chemotherapy

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• Advantages of Open Method
• No painful dressing changes
• Is visible for assessing wound for signs of
  infections
• Less equipment which means
• less ______

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• Disadvantages of Open Method
• Not suitable for burns of hands and feet
• More difficult to control body temperature
• Difficulty when transferring patient

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Topical Meds/Chemo

• Silvadene
• Silver Nitrate
• Sulfamylon

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Wound Care (cont)

• Closed Method
• Apply topical chemo and wrap with gauze, fluffs,
  kerlix
• Assess for
• constriction
• circulation
• checks

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Emergent Phase (cont)

• Anxiety r/t loss of skin and pain
• Allow verbalization of loss
• Explain all procedures
• Edema will subside in 2-4 days
• IV analgesics NOT I.M.s,
• why???

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Emergent Phase (cont)

• Elevate burned arms on pillows
• Give pain meds 30 minutes
• prior to treatments

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Emergent Phase (cont)

• Alteration in body temp (hypothermia) r/t loss of
  skin
• Set thermostats at warm temp in room
• Avoid drafts
• Heat lamp or warming lights placed over bed prn
  as ordered

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Emergent Phase (cont)

• Potential for injury r/t effects of stress
  response
• Stress diabetes What is the patho here???
• Curlings ulcer (associated with burn trauma
  patients)
• Gastroduodenal ulcer caused by increased gastric
  acid secretion

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Emergent Phase (cont)

• Potential for injury r/t effects of stress
  response
• Paralytic ileus (stress related)
• NPO, NG tube to suction
• Delirium (psychological stress)

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Emergent Phase (cont)

• Compartment syndrome r/t the effects
  circumferential burns
• Circulation is impaired
• Edema formation
• Occluded blood supply
• Ischemia
• Necrosis
• Gangrene

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Emergent Phase (cont)

• What is the treatment?
• Escharotomy

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Emergent Phase (cont)

• Renal Failure
• Hypovolemia (Why?)
• blood flow to kidneys
• Renal ischemia
• ARF may develop

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Emergent Phase (cont)

• Renal Failure
• Full thickness electrical burns
• Myoglobin from muscle cells released
• Hgb (from RBCs breakdown) released into
  bloodstream
• Blocks renal tubules

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Emergent Phase (cont)

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

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Emergent Phase (cont)

• Cardiac Function
• Arrhythmias due to electrolyte imbalance or
  electrical burns
• Hypovolemic shock due vascular bed depletion

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• Summary of Emergent Phase

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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 lt20 by grafting or
  wound healing

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Nursing Care During Acute Phase

• Skin/systemic infection r/t
• Loss of normal skin
• Formation of eschar
• Suppression of immune system
• Metabolic/hormonal alterations

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Acute Phase

• Interventions for Skin/Systemic Infection
• Hydrotherapy cart shower to debride
• Open/Closed dressing changes
• Topical chemotherapy
• Weekly cultures
• Systemic antibiotics

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Acute Phase (cont)

• Rules for Treating Infection in Burn Patients
• Rule 1 Burn trauma patients will be exposed to
  microorganisms no matter how germ free the
  environment

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• Rule 2 No single antibiotic or combo of
  antibiotics will fight all organisms
• Rule 3 First the bug, then the drug

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Acute Phase (cont)

• Excision Grafting
• Removal of necrotic tissue
• Eschar is removed until viable tissue is reached

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Acute Phase (cont)

• Significant amount of blood loss
• when excision occurs
• Hemostasis can occur
• clots may form between the
• graft and the
• wound

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Operative Debridement
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Acute Phase (cont)

• Clotting problem may be managed by excising wound
  one day and grafting the next day.
• Excised areas should be soaked with antibiotic
  solution

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Acute Phase (cont)

• Reasons for Grafting (priorities)
• Survival
• Function
• Cosmetic
• Synthetic Grafts
• BIOBRANE

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Types of Grafts

• Autograft or Autologous
• self
• Heterograft
• Different species
• Pig, bovine
• Homograft
• Cadaver
• Which are temporary vs permanent?

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Latest in Skin grafting

• Integra- Bovine collagen which is permanent
• Alloderm- derived from donated human skin
• CEA (cultured epithelial autograft)-
• unburned skin biopsied and sent to lab to
  grow with epithelial growth factor added.

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Graft Survival depends on

• Recipient bed must have adequate blood supply
• Graft must be in close contact with recipient bed
• Graft must be immobilized
• Free from infection

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Acute Phase (cont)

• GRAFTING

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Acute Phase (cont)

• GRAFTING

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Dermatome-harvesting donor skin from thigh
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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

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Acute Phase (cont)

• Can you describe this???

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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

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Acute Phase (cont)

• Alteration in Nutrition r/t hypermetabolism
• Goals are to minimize energy demands and to..
• Provide adequate calories to promote wound healing

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Acute Phase (cont)

• Interventions for altered nutrition
• Monitor bowel sounds
• High Protein High CHO
• Assess food preferences
• TPN as ordered

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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 clients readiness to talk
• Allow client to work through grief process
• Give honest, accurate information

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Acute Phase (cont)

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

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Interventions

• Assist with positioning
• ROM exercises
• Support O.T. P.T. efforts
• Always maintain eye contact with client

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III. Rehabilitation Phase

• From wound closure to optimal level of physical
  and psychosocial adjustment
• Potential for impaired home maintenance
• Discuss grief process, self-concept,
  resocialization process

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Rehabilitation Phase

• Instruct client on skin care
• Skin will itch, be dry, have a tight feeling
• Use Vaseline Intensive Care ES lotion, mild soaps
• Avoid direct sunlight (will cause
  hyperpigmentation)

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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

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Rehabilitation Phase

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

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Rehabilitation Phase

• Instruct client on skin care
• Need to wear Jobst to prevent keloid formation

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What are your assessment findings?