8/7/20151 Burns Linda Copenhaver. 8/7/20152 Introduction Incidence of Burns 1 million seek medical care annually Approximately 100K are hospitalized,

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BurnsLinda 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 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.

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

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 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 details…this 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 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 (respiratory acidosis or

alkalosis?) Bronchodilators Serial CXR’s 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 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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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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Fluid Volume Deficit (intravascular) r/t massive fluid shift to interstitial spacesAssess fluid needs:

Brooke FormulaEvans Formula

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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

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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

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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) 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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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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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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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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Elevate burned arms on pillows Give pain meds 30 minutes

prior to treatments

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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???

Curling’s ulcer (associated with burn trauma patients)

Gastroduodenal ulcer caused by increased gastric acid secretion

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Potential for injury r/t effects of stress response:Paralytic ileus (stress related)

NPO, NG tube to suctionDelirium (psychological

stress)

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Compartment syndrome r/t the effects circumferential burns

Circulation is impaired

Edema formation

Occluded blood supply

Ischemia

Necrosis

Gangrene

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What is the treatment?Escharotomy

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

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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 chemotherapyWeekly culturesSystemic 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

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

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?

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

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 preferencesTPN 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

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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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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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Instruct client on skin care:Need to wear Jobst to

prevent keloid formation

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What are your assessment findings?

Documents

8/7/20151 Burns Linda Copenhaver. 8/7/20152 Introduction Incidence of Burns 1 million seek medical care annually Approximately 100K are hospitalized,