Burns Lect

8/11/2019 Burns Lect

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Nursing Process Applied toAdults with Burns


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CAUSES

A. THERMAL

B. CHEMICAL

C. RADIATIOND. ELECTRICAL


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1. Assessment

1. Depth of Burn: Degree

a. superficial, first degree

(1)Epidermis only

(2)Minimal damage; heals with slight peeling


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1. Assessment

1. Depth of Burn: Degree

b. Partial thickness, second degree

(1)Epidermis and part of dermis

(2)Heals with scarring and depigmentation


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c. Full thickness, third degree

(1)Epidermis, entire dermis, andsometimes subcutaneous tissue

(2)Eschar sloughs, skin graftingnecessary


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Fourth-degree burnsdamage muscle,tendon, and ligament tissue, thusresult in charring and catastrophicdamage of the hypodermis.Fourth-degree burnsdamage muscle,tendon, and ligament tissue, thus

result in charring and catastrophicdamage of the hypodermis.


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2. Area of Burns: Rule of Nines


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3. Effects

a. Dilation of capillaries and smallvessels in affected areas

b. Increased capillary permeability

c. Plasma seeps into tissues, causingedema and blisters, or leaks out


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d. Fluid leakage greatest in first 24 to36 hours

e. Fluid loss reduces blood volume

f. Efficacy of circulation decreases

g. Blood pressure decreases

h. Hematocrit increases as a result


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4. Recovery

a. As capillary integrity increases, fluidreabsorbed into vascular space

b. If renal function normal, diuresisoccurs about two to five days

after injury, lasting severalweeks

c. If renal function impaired, fluid

overload and heart failuremayoccur


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B. Signs and symptoms

1.Pulmonary function

a. Types of injuries

(1) Carbon monoxide poisoning

(2) Smoke inhalation

(3) Upper airway injury

b. Restriction of breathing

c. Respiratory distress


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d. Burns of upper body

e. Singed nasal hairf. Hoarseness or voice change

g. Dry cough or sooty sputum

h. Bloody sputumi. Labored respirations

j. Altered arterial blood gases


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2. Circulatory function

a. Signs of shock, decreased BP, andincreased pulse

b. Potential changes in peripheralpulses of affected extremity

c. Hypovolemia

d. Decreased urine output

e. Hypothermia

f. Decreased GI motility and paralyticileus


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g. Increased blood glucose

h. Hyperkalemiai. Hyponatremia

j. Metabolic acidosis

k. Hemoconcentration, increasedhematocrit

l. Pain, can be very severe


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C. Complications

1. Scarring and contractures2. Loss of function

3. Psychological problems


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D. Treatment

1. Establishment and maintenance ofpatent airway

2. Determination of extent of burns

3. Continual reassessment

4. Treatment of shock

5. Fluid replacement

a. Colloids: blood, plasma, and plasmaexpander


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b. Electrolytes: normal saline, Ringerslactate, and Hartmanns solution

c. Multiple formulas for calculating theamount of fluid to be replaced , butup to 5,000 cc may be given first

eight hours after burn and 10,000 ccfirst 24 hours

d. Fluid replacement also based on urine

output, BP, and CVP


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6. IV antibiotics

7. Wound cleaning and debridement8. Topical antibacterials

9. Sterile environment

10. IV morphine for pain relief11. Nasogastric tube

12. Psychosocial counseling

13. Occlusive pressure dressings


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14. Skin grafting

a. Split thicknessb. Full thickness

15. High calories, high protein diet


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Implementations

A. Acute stage1. Monitor vital signs, especially for

airway occlusion

2. Monitor fluid status, BP, urine output,CVP, daily weights, I&O

3. Replace fluids as ordered

4. Maintain aseptic technique: gown,

gloves, mask (Reverse Isolation)


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5. Administer antibiotics as ordered

6. Administer IV morphine as needed7. Provide warmth

8. Monitor GI function, maintain NGtube as ordered (paralytic ileus)

9. Monitor peripheral pulses

10. Maintain adequate peripheralcirculation


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B. Treatment phase

1. Continue above implementations2. Clean and debride wounds asordered

(Hydrotherapy) e.g. shower carts

Exposure; Open; Occlusive method

Nursing Responsibility: Giveantimicrobial; analgesics


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3. Apply ordered topical antimicrobials

4. Prevent contractures with splints andpositioning

5. Prepare client for skin grafts

6. Provide donor site care

7. Maintain high protein, high caloriediet

8. Provide active and passive range of

motion


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9. Prevent other complications such asphlebitis, atelectasis, and skinbreakdown

10. Offer emotional support; encourageverbalization; refer to professional

counselor


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C. Rehabilitation phase

1. Encourage physical and occupationaltherapy

2. Teach client skin care such as cocoabutter or other lubricants to soften

skin

3. Assist client in regaining normalactivities of daily living

4. Apply splints as needed


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5. Teach client and significant otherswound care for after discharge

6. Use elastic or pressure bandages toprevent hypertrophic scarring

7. Encourage client to continue withrehabilitation including psychosocialcounseling

8. RACE; PRIORITY

Documents

Burns Lect