CARE OF PATIENTS WITH BURNS

NUR 240 Donna Ricketts, MSN, RN, OCN

INCIDENCE/PREVALENCE OF BURN INJURY

5th most common unintentional injury deaths 3rd leading cause of fatal home injuries 4,000 burn deaths each year

Factors: Age (<60) <40% TBSA Inhalation injury

PATHOPHYSIOLOGY OF BURN INJURY

• Skin changes resulting from burn injury

• Anatomic changes: Skin can regrow as long as part of the dermis is present. If the entire layer of dermis is burned then skin can no longer restore itself.

PATHOPHYSIOLOGY OF BURN INJURY

• Functional changes: loss in excretory ability through damage to sweat glands, changes in pain sensation, reduction in the ability to activate vitamin D, and psychosocial changes due to change in skin appearance.

• Temperature: Skin can tolerate temps up to 104.0 degrees F. above 158.0 degrees F cellular destruction is so rapid that even brief exposure damages the skin and the layers below.

DEPTH OF BURN INJURY • Severity depends on total body surface burned & depth • Degree of burn depends burn agent, length of exposure,

and temperature • Face, Feet, Hands, Perineum • Airway/Respiratory Involvement • Associated Trauma • Associated Medical Disease • Electrical Burns • Deep Chemical Burns

SUPERFICIAL BURN

Prolonged exposure to low-intensity heat or short (flash) exposure to high-intensity heat. Example: sunburn Redness, mild edema, pain, increased sensitivity Desquamation for 2-3 days Heals rapidly in 3-6 days

SUPERFICIAL PARTIAL-THICKNESS BURN

Caused by heat injury to the upper third of the dermis. Appear red, moist, and blanch. Nerve endings are exposed and pain sensation is increased. Any sensation is painful; touch or temperature change included. Typically heal within 10-21 days with no scar, but some minor pigment changes may occur.

DEEP PARTIAL-THICKNESS BURN Extend deeper into the dermis and fewer healthy cells remain. Blisters do NOT form due to dead tissue sticking to underlying tissue and burn layer does not readily lift off of the surface. Skin surface is red and dry with white areas in deeper parts (dry because fewer blood vessels are patent). Edema is moderate

DEEP PARTIAL-THICKNESS BURN (CONT)

Pain is less than with superficial burns because the nerve endings have been destroyed. These wounds can increase to full thickness if damage increases due to infection, hypoxia, or ischemia. Generally heal within 3-6 weeks, but scars do form.

FULL-THICKNESS BURN Destruction of the entire epidermis and dermis leaving no skin cells to repopulate. There is no regrowth Areas that are not closed by wound contraction will require skin grafting Characterized by a hard, dry, leathery eschar Eschar must be removed in order for healing to occur

FULL-THICKNESS BURN (CONT.)

If the wound is circumferential an escharotomy or fasciotomy may be required. May appear waxy white, deep red, yellow, brown, or black. Sensation is diminished or absent Healing time depends on establishing a good blood supply in the damaged areas and can range from weeks to months.

DEEP FULL-THICKNESS BURN Extend beyond the skin into the underlying faschia and tissues (damage muscle, bones, and tendons, leaving them exposed). Occur due to flame, electrical, or chemical injuries. Appears blackened and depressed and sensation is absent. Needs early excision and grafting. Grafting decreases pain and length of stay. Amputation may be needed when an extremity is involved.

FACIAL EDEMA

AMERICAN BURN ASSOCIATION CLASSIFICATION

TABLE 28-2

VASCULAR CHANGES FROM BURN INJURIES

Fluid shift—third spacing or capillary leak syndrome, usually occurs in the first 12 hour and can continue 24 to 36 hour Profound imbalance of fluid, electrolyte, and acid-base, hyperkalemia and hyponatremia levels.

VASCULAR CHANGES FROM BURN INJURIES

Hemoconcentration (Elevated blood osmolarity, HCT, and HGB). Fluid remobilization after 24 hr (when capillary leak stops and integrity is restored). Diuretic stage begins 48 to 72 hr after injury, hyponatremia and hypokalemia

CHANGES RESULTING FROM BURN INJURY

Changes include: Cardiac: caused by initial fluid shifts and hypovolemia.

Heart rate increases and cardiac output decreases because of initial fluid shifts. Cardiac output may remain low for 18-36 hours after the burn injury. Proper fluid resuscitation and oxygenation prevent further complications.

CHANGES RESULTING FROM BURN INJURY

Pulmonary: caused by superheated air, steam, toxic fumes, or smoke.

Major cause of death and most likely to occur when burn takes place indoors. Respiratory failure occurs due to the following:

– Airway edema during fluid resuscitation. – Pulmonary capillary leak – Chest burns that restrict movement – Carbon monoxide poisoning

CHANGES RESULTING FROM BURN INJURY

GI (Curling’s ulcer): caused by decreased blood flow Acute gastroduodenal ulcer that develops with stress after severe injury. Typically develops within 24 hours of injury as a result of reduced GI blood flow and mucosal damage. Treated with H2 blockers, PPI, GI protectants (sulcrafate), and early enteral feeding.

CHANGES RESULTING FROM BURN INJURY

Metabolic: caused by increased metabolism Increased production of catecholamine's, antidiuretic hormone, aldosterone, and cortisol. Oxygen use increases and caloric needs increase (2-3x). Stress response results in catabolism, uses glucose and calories, increase urine nitrogen loss Increase core body temperature d/t hypermetabolic state

CHANGES RESULTING FROM BURN INJURY

Immunologic: Loss of skin = loss of protective barrier Injury activates anti-inflammatory response and often decreases immunologic function Topical and systemic antibiotics, general anesthesia, blood transfusions and surgical stress further decrease immunologic function.

CHANGES RESULTING FROM BURN INJURY

Compensatory Responses to Burn Injury: Inflammatory compensation: triggers healing (it can also be responsible for some of the complication that occur during fluid shift). Sympathetic nervous system: compensation occurs when any physical or psychological stressors are present.

SYMPATHETIC NERVOUS SYSTEM COMPENSATORY RESPONSE

ETIOLOGY OF BURN INJURY Dry heat (open flame; house fires or explosions) Moist heat (scald; injury from hot liquids or steam) Contact burns (hot metal, tar, or grease contact the skin; often resulting in full thickness injury) Chemical injury (accidents in home, at work, or as a physical attack)

ETIOLOGY OF BURN INJURY

Electrical injury (high voltage and low voltage, can be very misleading) Radiation injury (injury depends on time and type; determined by the type of radiation, distance from the source, duration of exposure, absorbed dose, and depth of penetration into the body)

ELECTRICAL BURN • Surface injuries may look small, but

internal damage may be huge. • High voltage is greater than 1000 volts. • Injury depends on the type of current,

pathway of flow, local tissue resistance, • Once skin resistance is overcome current

flows throughout the body. • Current flows throughout the involved

body part • Bone is high resistance; current flows

around the bone, damaging the surrounding tissues.

• It is difficult to know the exact path the current takes; best guestimate is to evaluate the entry and exit sites.

Fig. 28-9

EMERGENT PHASE OF BURN INJURY

First phase, or emergent phase, continues for about 48 hours. Goals of management include:

Secure airway Support circulation—fluid replacement Prevent infection Maintain body temperature Provide emotional support

Age-Related Changes in Older Adult: Chart 28-2

INJURIES TO THE RESPIRATORY SYSTEM Direct airway injury Carbon monoxide poisoning Thermal injury Smoke poisoning Pulmonary fluid overload External factors

RESPIRATORY BURN INJURY

Inhalation injuries are present in 5-15%of patients admitted Damage depends on the type of fire source, temperature, environment, and types of toxic gas generated. The following burn locations determine the risk of injuries: Lips, Face, Ears, Neck, Eyelids, Eyebrows, Eyelashes

Carbon monoxide poisoning results from exposure to the colorless, odorless and tasteless gas. It replaces the oxygen molecule on hemoglobin (carboxyhemoglobin CoHb) Table 28-4.

CARDIOVASCULAR ASSESSMENT

Hypovolemic shock is a common cause of death in the emergent phase in patients with serious injuries.

Monitor vital signs, (invasive BP monitoring,ECG)

Monitor cardiac status, especially in cases of electrical burn injuries.

RENAL/URINARY ASSESSMENT

Changes are related to cellular debris and decreased renal blood flow. Myoglobin is released from damaged muscle and circulates to the kidney. Assess renal function, blood urea nitrogen, serum creatinine, and serum sodium levels. Examine urine for color, odor, and presence of particles or foam.

SKIN ASSESSMENT

Determine size and depth of injury. Determine percentage of total body surface area affected. Use "rule of nines," using multiples of 9% of total body surface area. What about children?

RULE OF NINES

• An adult who has been burned, the percent of the body involved can be calculated as follows:

• Head = 9% • Chest (front) = 9% • Abdomen (front) = 9% • Upper/mid/low back and buttocks = 18% • Each arm = 9% (front = 4.5%, back = 4.5%) • Groin = 1% • Each leg = 18% total (front = 9%, back = 9%) • As an example, if both legs (18% x 2 = 36%), the groin (1%) and the

front chest and abdomen were burned, this would involve 55% of the body.

RULE OF NINES

RULE OF NINES FOR SMALL CHILD BSA

Head and neck equal .....................18 % Anterior trunk equals ....................18 % Posterior trunk equals ...................18 % Upper extremities (each 9%) ........18 % Lower extremities (each 6.75%)....27 % Perineum .......................................1 %

EXAMPLE

Pt presents to the ED with the following areas burned:

Front of the chest (9) Front of the abdomen (9) Face (with singed nasal cilia and burned eyelashes) (4.5) Front of the Forearms ( 2.25each 4.5 total) What is the patients TBSA? 27% Would this patient be at risk for inhalation injury?

RULE OF PALMS

The surface of the patient's palm represents approximately 1% of body surface area and is helpful in estimating the area of small burns.

GASTROINTESTINAL ASSESSMENT

Changes in GI function are expected. Decreased blood flow and sympathetic stimulation during the emergent phase cause reduced GI motility and paralytic ileus. Assess for GI bleeding.

NURSING CARE FOR A PATIENT WITH BURNS

http://www.youtube.com/watch?v=lhreMRjbaJE

BURNS: NONSURGICAL MANAGEMENT

IV fluids: Parkland formula Monitoring patient response to fluid therapy

Watch for overload Monitor respiratory and cardiac activity

Drug therapy

Antibiotics Antimicrobials IV pain medication

PARKLAND FORMULA FOR FLUID RESUSCITATION

4ml x Kg x TBSA= total fluid infused over the first 24 hours.

Infuse1/2 over 1st 8 hours

Infuse1/2 over last 16 hours

EXAMPLE

• Pt weighs 50 kg • 80% TBSA burned

• Formula: 4ml x kg x TBSA 4 x 50 x 80 = 16000 ml total needed to be given

8000 ml's given in the first 8hrs 8000 ml's given over the following16hrs

BURNS: SURGICAL MANAGEMENT Escharotomy: surgical incision of the eschar and superficial fascia of the chest or a circumferentially burned limb in order to permit the cut edges to separate and restore blood flow to unburned tissue. Fasciotomy: surgical procedure that cuts away the fascia to relieve tension or pressure.

ACUTE PHASE OF BURN INJURY

Begins about 36 to 48 hr after injury and lasts until wound closure is completed Care directed toward continued assessment and maintenance of the cardiovascular and respiratory systems, as well as toward GI and nutritional status, burn wound care, pain control, and psychosocial interventions

ASSESSMENT

Assessments includes: Cardiopulmonary (hypovolemic shock & pneumonia) Neuroendocrine (increased metabolism can deplete nutritional stores. Weigh pt daily; 2% weight loss is a mild deficit, 10% or greater requires dietary modification)

ASSESSMENT (CONT)

Immune (open wounds and reduced immune function causes infection. Watch for gram +, gram-, and yeast infections) Musculoskeletal (result of other injuries) immobility, healing process, and treatment; provide active and passive ROM).

NONSURGICAL MANAGEMENT: ACUTE PHASE

Burn injuries are debrided 1-2 times daily • Mechanical débridement:

– Hydrotherapy (immerse pt in tub or use shower and use mild detergent. Water temp must be consistent and room temp). Remove loose tissue with forceps/scissors

• Enzymatic débridement: – Autolysis

• Disentegration of tissue by pt’s own cellular enzymes, used very seldom with large burns due to prolonged hospital stays and increased risk for infection.

– Collagenase • Topical enzyme agents (Santyl)are applied directly to the burn

in a once daily dressing change. Enzymes digest the collegen in necrotic tissues.

DRESSING THE BURN WOUND Standard wound dressings

Multiple layers of gauze applied over topical agents. Number of layers depend on depth of injury, amount of drainage expected, area injured, patients mobility, frequency of dressing changes. Changed every 8-12 hours. Drug Therapies with Burns: Pages 534-535

http://www.youtube.com/watch?v=A8-ai2kwwLI

DRESSING THE BURN WOUND BIOLOGIC DRESSINGS:

Homograft: human skin obtained from a cadaver. Cost $750-$1500 per square foot. Has to be thawed in a warm bath prior to use. Heterograft: skin from other species; pigskin. Must check daily for adherence. Amniotic membrane: (large size and low cost). Disintegrates in about 48 hours. Used mostly for chemical burns in eyes. Cultured skin: Grown from a small area of the pts skin (increased length of time and large prices). Artificial skin: made from beef collagen and shark cartilage

DRESSING THE BURN WOUND (CONT’D) BIOSYNTHETIC DRESSINGS:

Biobrane: used in the treatment of clean and superficial partial thickness burns. Nylon fabric that is partially embedded into silicone film. Forms an adherent bond until epithelialization has occurred. Porous silicone allows exudate to pass through.

SYNTHETIC DRESSINGS:

Made of solid silicone and plastic membranes. Substitute for a antimicrobial, standard, and biologic dressings. Applied to clean wound and stay in place until they fall off or are removed. Transparent, easy to assess wound.

SURGICAL MANAGEMENT

Surgical Excision Performed early in the post burn period. Common treatment for full thickness and deep partial thickness. Approximately within 5 days of burn injury and as needed until all burns are closed permanently. Tangential: surgeon removes very small layers of burn surface until bleeding tissue is reached. Fascial: cuts away the burn to the level of the superficial fascia. Performed on very deep and extensive burns. Blood loss is minimal.

SURGICAL MANAGEMENT (CONT.)

Wound Covering: Skin grafting

Placed on a clean granulated bed or on a necrotic area that has just had tissue removed. Can be difficult to autograft due to available TBSA to choose donor site. Healing time is slower for a mesh graft because the skin must fill in the open areas and attach to the granulation bed.

MESHED AUTOGRAFT Split Thickness Skin Graft STSG

MINIMIZING INFECTION

Patient more at risk from auto-contamination and cross contamination Signs: Foul-smelling discharge, Fever, Blood Cx Wound site colonization, WBC Interventions focus on prevention and removing infected tissue

NONSURGICAL MANAGEMENT

Drug therapy Burn conditions support the growth of clostridium tetani; pt must be given tetanus immunization. Topical antimicrobials may also be used (silvadene and flamazene). These medications should not be applied to freshly grafted areas because they may inhibit cell growth. Topical antibiotics may be applied open or closed (with or without a dressing).

NONSURGICAL MANAGEMENT

Isolation therapy Reduces cross contamination. Pt should be placed in a near-sterile environment. Asepsis & Early detection of infection

Environmental management

Disposable equipment should be used as much as possible. Visitors should be restricted.

NUTRITION MANAGEMENT

Maintain adequate nutrient intake Assess: weight, food intake, H&H, serum albumin, glucose Daily calorie count Nutritional needs exceed 5,000kcal/day Oral therapy after GI tract motility returns

MOBILITY MANAGEMENT Maintain or regain an optimal mobility Muscle movement Joint movement Walking Body positioning performance Positioning, ROM exercises, ambulation, pressure dressings after grafts heal Chart 28-6

REHABILITATIVE PHASE OF BURN INJURY

Rehabilitation begins with wound closure and ends when the patient returns to the highest possible level of functioning. Emphasis during this phase is on psychosocial adjustment, prevention of scars and contractures, and resumption of pre-burn activity.

REHABILITATIVE PHASE OF BURN INJURY Understand stages of grief Coordinate with psychologist, psychiatrist, social worker, clergy, religious leader Provide information on counseling and support groups for patient and family Reconstructive and Cosmetic surgery

This phase may last years or even a lifetime if patient needs

to adjust to permanent limitations.

REHABILITATIVE PHASE OF BURN INJURY (CONT’D)

Disturbed body image: it can be difficult for the burn patient to have a positive outlook of their own body appearance and function. Pt should demonstrate these behaviors:

Willingness to touch the affected body part Adjustment to changes in body function Willingness to use strategies to enhance appearance and function