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04/21/23 1
BurnsLinda Copenhaver
04/21/23 2
Introduction
Incidence of Burns
1 million seek medical care annually
Approximately 100K are hospitalized, 70K require ICU
stays
04/21/23 3
Bonus' Site - KitchenOilFire.wmv
04/21/23 4
Types of Burn Injury
Thermal Chemical Electrical Radiation
04/21/23 5
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
04/21/23 6
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
04/21/23 7
Chemical Burns
Remove person from contact with agent
Flush with water continuously
Remove affected clothing if possible
04/21/23 8
Electrical burns Coagulation necrosis Severity depends on voltage, amount of
resistance, time,
and current
pathways.
Electrical Burn–Back
Fig. 25-2 B
04/21/23 10
Frequently only entry (yellow-white) and exit (blow out) wounds are visible
Extensive tissue damage is masked
How can we evaluate “masked tissue damage”???
04/21/23 11
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
04/21/23 12
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
04/21/23 14
Depth of Burns Superficial Partial Thickness Burn (1st
degree) Epidermis involvedSunburn, UV light, mild radiation,Pink to redSlight edemaMild pain
04/21/23 15
Depth of Burns Deep Partial Thickness (2nd)
Epidermis and some of dermis, is painful, red, blisters
04/21/23 16
Depth of Burns
Deep Partial Thickness (2nd)
Epidermis and Dermis
Very Painful, edema, pale
Moist or dry
Some
blisters
04/21/23 17
Depth of Burns (cont) Full Thickness Burns (3rd)
Epidermis, Dermis, and Subcutaneous tissue burned
Nerve endings destroyed Little or no pain
04/21/23 18
Depth of Burns (cont)
Full thickness (4th degree) Involves past the 3 layers
down to the bone and/or organs
04/21/23 19
Extent of Burns Rule of Nines
Easy to remember, quick method
Rule of Nines Chart
Fig. 25-4 B
04/21/23 21
Lund & Browder More accurate, more time spent
calculating TBSA burned
Lund-Browder Chart
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
04/21/23 23
04/21/23 24
Survival Prediction
Depth of Burns Extent of Burns Location of Burns Age of Client Risk Factors Major vs Minor Burns
04/21/23 25
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
04/21/23 26
Emergent Phase (cont)
Also called FLUID ACCUMULATION PHASE
The greatest initial threat to a major burn victim is hypovolemic shock
See outline for details…this is a DING DING!
04/21/23 27
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
04/21/23 28
What are the Priorities in this patient??? Is this patient a candidate for a
major burn center?
04/21/23 29
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.
04/21/23 30
Signs & Symptoms of Carbon Monoxide Poisoning Edema of Airway Hoarseness Dysphagia Stridor Copius Secretions usually
black tinged Substernal Retractions
04/21/23 31
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???
04/21/23 32
Nursing Care during Emergent Phase (cont) Impaired Gas Exchange r/t
mucosal edema throughout respiratory tract secondary to smoke inhalation, hot air, chemical gases
04/21/23 33
Interventions: Early intubation to prevent
trach placement Ventilation Humidified O2 100% ABG’s (respiratory acidosis or
alkalosis?) Bronchodilators Serial CXR’s and VQ scan
04/21/23 34
What do you assess for here???
04/21/23 35
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
04/21/23 36
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?
04/21/23 37
What are your #1 priorities in this patient?
Patient #1 Patient #2
04/21/23 38
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
04/21/23 39
Escharotomy of chest and arm What is the pathophysiology here?
04/21/23 40
Emergent Phase (cont)
Fluid Volume Deficit (intravascular) r/t massive fluid shift to interstitial spacesAssess fluid needs:
Brooke FormulaEvans Formula
04/21/23 41
Parkland Baxter FormulaMost widely usedFormula:
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
04/21/23 42
Okay Nurses Let’s Calculate…
What would the fluid replacement be for patient who weighed 60kg and had 30% TBSA burned???
1st 8 hours= _____or ____cc/hr2nd 8 hours= _____or ____cc/hr
3rd 8 hours= _____or ____cc/hr
04/21/23 43
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?
04/21/23 44
Insert foley catheter to monitor output. What should urine output be in an adult???
Frequent vital signs SBP>100 Pulse<100 RR 16-20
04/21/23 45
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???
04/21/23 46
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
04/21/23 47
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
04/21/23 48
Hydrotherapy in cart (water is heated to approximately 104 degrees)
< 30 minutes to prevent _____
04/21/23 49
04/21/23 50
Hubbard Tank (old method)
04/21/23 51
Hydrotherapy Cart
What does hydrotherapy accomplish?
04/21/23 52
Wound Care
Open Method Apply topical chemotherapy
04/21/23 53
Advantages of Open Method:
No painful dressing changes Is visible for assessing wound
for signs of infections Less equipment which
means…
less ______
04/21/23 54
Disadvantages of Open Method:
Not suitable for burns of hands and feet
More difficult to control body temperature
Difficulty when transferring patient
04/21/23 55
Topical Meds/Chemo
Silvadene
Silver Nitrate Sulfamylon
Application of Silver Sulfadiazene to Moistened Gauze
Fig. 25-10
04/21/23 57
Wound Care (cont) Closed Method
Apply topical chemo and wrap with gauze, fluffs, kerlix
Assess for
constriction;
circulation
checks
04/21/23 58
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???
04/21/23 59
Emergent Phase (cont)
Elevate burned arms on pillows Give pain meds 30 minutes
prior to treatments
04/21/23 60
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
04/21/23 61
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
04/21/23 62
Emergent Phase (cont)
Potential for injury r/t effects of stress response:Paralytic ileus (stress related)
NPO, NG tube to suctionDelirium (psychological
stress)
04/21/23 63
Emergent Phase (cont)
Compartment syndrome r/t the effects circumferential burns
Circulation is impaired
Edema formation
Occluded blood supply
Ischemia
Necrosis
Gangrene
04/21/23 64
Emergent Phase (cont)
What is the treatment?Escharotomy
04/21/23 65
Emergent Phase (cont)
Renal Failure
Hypovolemia (Why?) blood flow to kidneys
Renal ischemia ARF may develop
04/21/23 66
Emergent Phase (cont) Renal Failure
Full thickness & electrical burns
Myoglobin from muscle cells released
Hgb (from RBCs breakdown) released into bloodstream
Blocks renal tubules
04/21/23 67
Emergent Phase (cont)
What is the treatment for these 2 renal problems????
04/21/23 68
Emergent Phase (cont)
Cardiac Function
Arrhythmias due to electrolyte imbalance or electrical burns
Hypovolemic shock due vascular bed depletion
04/21/23 69
Summary of Emergent Phase:
04/21/23 70
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
04/21/23 71
Nursing Care During Acute Phase Skin/systemic infection r/t
Loss of normal skinFormation of escharSuppression of immune
systemMetabolic/hormonal
alterations
04/21/23 72
Acute Phase Interventions for
Skin/Systemic Infection:
Hydrotherapy cart shower to debride
Open/Closed dressing changes
Topical chemotherapyWeekly culturesSystemic antibiotics
04/21/23 73
Acute Phase (cont)
Rules for Treating Infection in Burn Patients:
Rule #1 Rule #2Rule #3
04/21/23 74
Acute Phase (cont) Excision & Grafting
Removal of necrotic tissue Eschar is removed until viable
tissue is reached
04/21/23 75
Acute Phase (cont)
Significant amount of blood loss
when excision occurs
Hemostasis can occur
clots may form between the
graft and the
wound
Grey's Anatomy---Burn Trauma Episode on 10/22/09
04/21/23 76
Operative Debridement
04/21/23 77
04/21/23 78
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
04/21/23 79
Acute Phase (cont)
Reasons for Grafting (priorities)
Survival Function Cosmetic
Synthetic Grafts BIOBRANE
04/21/23 80
Types of Grafts
Autograft or Autologous self
Heterograft Different species
Pig, 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
04/21/23 83
Acute Phase (cont)
GRAFTING
04/21/23 84
Acute Phase (cont)
GRAFTING
Dermatome-harvesting donor skin from thigh
04/21/23 85
04/21/23 86
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
04/21/23 87
Acute Phase (cont)
Can you describe this???
04/21/23 88
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
04/21/23 89
Acute Phase (cont)
Alteration in Nutrition r/t hypermetabolismGoals are to minimize
energy demands and to..Provide adequate calories
to promote wound healing
04/21/23 90
Acute Phase (cont)
Interventions for altered nutrition:
Monitor bowel soundsHigh Protein High CHOAssess food preferencesTPN as ordered
04/21/23 91
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
04/21/23 92
Acute Phase (cont)
Self-care Deficit r/t restricted movement/contractures/muscle atrophy
04/21/23 93
Interventions
Assist with positioning ROM exercises Support O.T. & P.T. efforts Always maintain eye contact with
client
04/21/23 94
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
04/21/23 95
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)
04/21/23 96
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
04/21/23 97
Rehabilitation Phase Instruct client to wear JoBST
pressure garment up to 1 year
04/21/23 98
Rehabilitation Phase
Instruct client on skin care:Need to wear Jobst to
prevent keloid formation
04/21/23 99
What are your assessment findings?