Burns

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BurnsLinda Copenhaver

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Introduction Incidence of Burns

½ million seek medical care annually

Approximately 40K are hospitalized Where do most burn trauma injuries

occur? 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 possible…WHY?

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.

Electrical Burn–Back

Fig. 25-2 B

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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

Cross Section of Skin

Fig. 25-3

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Depth of Burns Superficial Partial Thickness Burn (1st degree)

Epidermis involvedSunburn, UV light, mild radiation,Pink to redSlight edemaMild pain

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Depth of Burns Deep Partial Thickness (2nd)

Epidermis and some of dermis, is painful, red, blisters

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Depth of BurnsDeep Partial Thickness (2nd)

Epidermis and DermisVery Painful, edema, paleMoist or dry

Blisters

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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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Rule of Nines Chart; quick & easy

Fig. 25-4 B

Lund-Browder Chart; More accurate

Fig. 25-4 A

Burn Unit Referral Criteria Deep Partial Thickness burns > 10% TBSA Burns that involve the face, hands, feet,

genitalia, perineum, or major joints Full thickness burns in any age group Electrical burns, including lighting 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

Let’s do the Patho on p. 479 Lewis…this is a DING DING!

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Some Questions….. The nurse knows that in a patient

who has full thickness burns, that the burns must involve the:

a) Muscleb) Dermisc) Tendonsd) Bone

A 40 year old male sustains burns to his anterior torso following an explosion of a fuel tank. The burned area is brown and leather like. The client does not c/o pain. The nurse should conclude that the client has burns that are:

a) superficial partial thickness b) moderate partial thickness c) deep partial thickness d) full thickness

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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 Skin will appear cherry red

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Cherry red skin appearance

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Interventions for CO Poisoning: Assess for S&S CO poisoning (mild to

severe) Humidified O2 100% via face mask High Fowler’s 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% ABG’s Bronchodilators CXR’s

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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 client’s 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

constrictionEscharotomies 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 spacesAssess fluid needs:

Brooke FormulaEvans Formula

Parkland Baxter Formula Most widely used

Formula

LR 4ml X kg body weight X TBSA % burned

½ total amount given 1st 8 hours ¼ total amount given next 8 hours ¼ total amount given next 8 hours

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Okay Nurses Let’s Calculate What would the fluid replacement be for a

patient who weighed 60kg and had 30% TBSA burned???

1st 8 hours= _____ or ____ml/hr 2nd 8 hours= _____ or _____ml/hr 3rd 8 hours= ______ or _____ml/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 SBP>100 Pulse<100 RR 16-20

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Emergent Phase (cont)

Monitor Electrolytes and Hematocrit; tells you about fluid shift. What should Hct be doing as

time progresses???

Using the Parkland formula, a client who has full and deep partial thickness burns to 30% of his body is to receive 6000ml of fluid over the next 24 hours. You would administer: 1/3, 1/3 and 1/3 during each 8 hour period 1/2, 1/4, and 1/4 during each 8 hour period 1/4, 1/4, 1/4 and 1/4 during each 6 hour period 1/8, 1/8, 1/4, and 1/2 during each 6 hour period

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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)

< 30 minutes to prevent _____

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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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Topical Meds/Antimicrobials Silvadene cream

Silver Nitrate or silver impregnated dressings such as Silverlon or Acticoat

Sulfamylon cream

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Application of Silver Sulfadiazene to Moistened Gauze

Fig. 25-10

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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) 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 (~85 degrees)

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Emergent Phase (cont) Potential for injury r/t effects of

stress response:

Stress diabetes What is the patho here???

Curling’s 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 suctionDelirium (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

<20% by grafting or wound healing

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Nursing Care During Acute Phase Skin/systemic infection r/t

Loss of normal skinFormation of escharSuppression of immune

systemMetabolic/hormonal

alterations

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Acute Phase Interventions for

Skin/Systemic Infection:

Hydrotherapy cart shower to debride

Open/Closed dressing changes

Topical antimicrobialsWeekly culturesSystemic antibiotics

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Acute Phase (cont) Rules for Treating Infection in Burn

Patients:

Rule #1---no certain protocolRule #2---no matter how aseptic the

environment, microorganisms are present

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

Operative Debridement

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The RN just received report on the burn unit. Which client requires the most immediate assessment or intervention? a) 22 yo old admitted 4 days previously with

facial burns due to a house fire who has been crying since recent visitors left

b) 34 yo who returned from skin graft surgery 3 hours ago and is c/o 8 out of 10

c) 45 yo with deep partial thickness leg burns who has temp of 102.6 and a bp of 98/46

d) 57 yo who was admitted with electrical burns 24 hours ago and has K+ level of 5.6mEq/L

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Acute Phase (cont) Bleeding problem may be

managed by debridement and surgical excision of the eschar one day and grafting to that site the next day.

Topical epinephrine or thrombin is applied to decrease bleeding from that area

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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 speciesPig, bovine

Homograft Cadaver

Which are temporary vs permanent?

New Advanced Grafts Cultured Epithelial Autograft (CEA)

Patient’s own skin cells grown in culture dish—Permanent

Latest in Skin Grafting--More options for Permanent Grafts

New Advanced Grafts

Integra

Bovine collagen and glycosaminoglycan bonded to silicone membrane-Permanent

AlloDerm Acellular dermal matrix derived from

donated human skin-Permanent

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Acute Phase (cont) GRAFTING

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Acute Phase (cont) GRAFTING

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

hypermetabolismGoals 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 soundsHigh Protein High CHOAssess food preferencesDaily calorie countTPN 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 client’s readiness to talk Allow client to work through grief

process Give honest, accurate information

A client with deep partial and full thickness TBSA burned is 28% is receiving hydrotherapy. The nurse should assess for which of the following complications? a) hypernatremia b) dehydration c) edema d) hypothermia

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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/integration back into social and work environment

Discuss grief process, self-concept, resocialization process

Sexuality issues, will I be a productive person? Will I be a good parent/partner?

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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

Use Benadryl for itchingAvoid 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