Integumentary: Burns

Marnie Quick, RN, MSN, CNRN

Skin layers

Types of burns Thermal Chemical Thermal Radiation

Thermal burn

Cool burn with cold water until pain is relieved- Do not apply to more than 20% body surface- hypothermia may occur

Chemical burn from sulfuric acid

Electrical burns: top picture- toe Leg bottom picture- mouth

Depth of burn: Layers of skin and burns

Depth of burn: First degree burn to third degree

First degree burns

Second degree burn- note blisters

Second degree burn

Full thickness third degree burn All layers skin

Full thickness

Involves past the 3 layers down to the bone and/or organs

Extent of Burn: Rule of Nines Lund & Browder- age

What are the Priorities in this patient??? Is this patient a candidate for a

major burn center?

Common manifestations/complications of Major Burn

1. Integumentary system eschar formation necrotic tissue hard, leathery must be removed for

healing to take place

Common manifestations/complications Major Burn 2. Cardiovascular

Burn shock- third spacing (hypovolemic) 24-36 hrs Blood vess damaged> inc cap permeability H2O, Na & serum albumin> intestial space(3rd space) HCT and blood viscosity increases > 40% burn causes dec cardiac contractibility & CO Electrical burn can cause arrhythmias/cardiac arrest Compartment syndrome of extremities/torso as edema

compresses blood vessels and nerves- may need escharotomy

Third spacing

Burn with escarotomy

Before the escharotomy, how would this eschar affected his respirations?

Escarotomy

Common Manifestations Complications Major Burn

3. Respiratory Direct inhalation injury/systemic response (ARDS) Upper airway thermal injury- esp if burned in

enclosed space (room) & breaths in hot air. May be no outward sign of burn- look for soot, nasal hairs

Laryngeal spasms as edema peaks in 34-48 hrs Bronchial congestion and infection Intersitial pulmonary edema; alveolar collapse CO poisoning- 200 X’s greater affinity for

hemoglobin- hypoxia> headache to coma sym

What are your #1 priorities in this patient?

Patient #1 Patient #2

What do you assess for here???

Common Manifestations Complications Gastrointestional

Paralytic ileus > increased risk for aspiration Stress ulcer (Curling’s ulcer) ck pH Ischemia of intestine increases intestinal mucosal

permeability> bacteria can cause systemic sepsis, ARDS and multiple organ failure

Common Manifestations/Complications Urinary Urinary-

Renal blood flow/GFR decrease causing release ADH

Myoglobinurea- dark urine may block renal tubules

Common Manifestations/complications Immune system and metabolism Immune system

Capillary leak- serum levels immunogloblin decreased

Opportunistic infections can be fatal Most common source infection/septicemia- clients

own GI track Metabolism

BMR increases 2X’s, more if complications Hypermetabolism continues until wound closure Body weight and temperature drop- shivering inc met

Common Manifestations/Complications- Pain

Where are nerve ending?

Morphine/Fentanyl Give IV in acute

stage due to fluid shift---No IM’s

Therapeutic Interventions Major Burns Stage one: Emergent/resuscitative Stage

Onset injury to successful fluid resuscitation Major concern- Fluid Resuscitation- prevent

hypovolemic shock 2 large bore IV’s in unburned area to restore bl

vol due to inc capillary permeability> 3rd spacing Guidelines burns >20% TBSA- Parkland formula

or Modified Brooke formula Need Weight and % TBSA burned to calculate

Lactated Ringers solution 1st 24 hrs then add 5% Dextrose to crystalloid fluid

50% of formula volume in first 8 hrs; rest over next 16 hrs; then maintain urinary output

Hourly output 30-50 cc/hr (foley); heart rate less than 120/min; hemodynamic monitoring

Elevate edematous part; escharotomy

Elevate arms to decrease swelling also note escarotomy of arms and chest- assess CMS

Other therapeutic interventions during Stage one: emergent/resucitative stage First aide treatment to limit severity of burn Prevent heat loss through burn- warm envir Respiratory involved-

intubation/ventilation with PEEP/humidified O2 bronchodilators mucolytic agents to liquefy secretions TCDB HOB 30

GI- Pepcid; NG tube when gut ready- antacids

Third spacing- Note edema of the face decreasing

Summary of Emergent Phase:

Therapeutic Interventions Major Burns Stage 2: Acute Stage

Start of diuresis and ends with closure of burn Major concern in this stage- infection Most common cause infection- pts own GI track Wound management-

hydrotherapy, debridement of eschar topical antimicrobial creams (open/closed method) splints/exercise prevent contractures; Excision/grafting of 3rd degree (temporary cover 2nd )

Hydrotherapy: Hubbard Tank

Cleaning and debriment in Hubbard

Topical broad spectrum antimicrobials (p.425)

Silvadene

Silver Nitrate Sulfamylon

Wound Care Open Method Apply topical chemotherapy

Wound Care- Closed method

Apply topical chemo and wrap with gauze, fluffs, kerlix

Assess for constriction; circulation checks

Elevate burned arms on pillows Give pain meds 30 minutes

prior to treatments

Skin will grow together if not separated

Several patients utilizing closed method Who is that nurse with white stockings& cap?

Excision & Grafting Removal of necrotic tissue Eschar is removed until viable

tissue is reached

Acute Phase- grafting

Acute Phase Autograft-

on right- donor site Permanent if no

infection

Temporary grafts Homograft- cadaver Heterograft- animal Synthetic

Interventions Assist with positioning ROM exercises Support O.T. & P.T. efforts

Therapeutic Interventions: Stage 3: Rehabilitation Stage

Wound closure to highest level of function- years Major concern is psychosocial adjustment Prevent/reduce hypertrophic scares- pressure

garments Skin care Potential for repeated cosmetic surgeries

Keloid formation

Rehabilitation Phase- Pressure garments

Pertinent Nursing Problems/interventions

Impaired skin integrity Deficient fluid volume Acute pain Risk for infection Impaired physical mobility Imbalanced nutrition: less than body req Powerlessness

What are your assessment findings?

What are your nursing priorities for this patient?