Luka bakar

JUNI 10,FFJUNI 10,FF 11

LUKA BAKARLUKA BAKAR(BURN)(BURN)


Third – Degree Burn Third – Degree Burn


Rule of NinesRule of Nines

surface of surface of patient’s patient’s

palm = 1% BSA palm = 1% BSA


Burn woundsBurn wounds occur when occur when there is contact between there is contact between

tissue and an energy tissue and an energy source, such as heat, source, such as heat, chemicals, electrical chemicals, electrical current, or radiation.current, or radiation.

Burns and Patient Burns and Patient ManagementManagement


The resulting effects of The resulting effects of the burn are influenced the burn are influenced

by the:by the:

intensity of the energyintensity of the energy duration of exposureduration of exposure type of tissue injuredtype of tissue injured


Burn StatisticsBurn Statistics At least 50% of all burn accidents can At least 50% of all burn accidents can

be preventedbe prevented children playing with fire account for children playing with fire account for

more than one-third of preschool more than one-third of preschool deaths by firedeaths by fire

In the US, approximately 2.4 million In the US, approximately 2.4 million burn injuries are reported each year.burn injuries are reported each year.

Burn injuries are second to motor Burn injuries are second to motor vehicle accidents as leading cause of vehicle accidents as leading cause of accidental death in the USaccidental death in the US


What 2 types of clients What 2 types of clients account for 2/3 of all account for 2/3 of all

burn fatalities?burn fatalities?

Older adultsOlder adults

• Children (especially Children (especially preschool aged children)preschool aged children)


Where do most burns Where do most burns occur?occur?

Children, newborn to 4 y.o, from Children, newborn to 4 y.o, from kitchen and then the bathroomkitchen and then the bathroom

ages 5-74, most burn injuries occur ages 5-74, most burn injuries occur outdoors with next area-kitchenoutdoors with next area-kitchen

ages 75 and above, kitchen and then ages 75 and above, kitchen and then outdoorsoutdoors


Major cause of fires in the Major cause of fires in the homehome

Carelessness with cigarettes!!Carelessness with cigarettes!! Hot water from water heaters set Hot water from water heaters set

at high levels above 140 degrees F at high levels above 140 degrees F (60 degrees C)(60 degrees C)

cooking accidentscooking accidents space heatersspace heaters combustibles - gasoline, lighter combustibles - gasoline, lighter

fluids, etc.fluids, etc. chemicalschemicals


Types of Burn InjuryTypes of Burn Injury Thermal burnsThermal burns-can be caused by flame, -can be caused by flame,

flash, scald, or contact with hot objectsflash, scald, or contact with hot objects Chemical burnsChemical burns-are the result of tissue -are the result of tissue

injury and destruction from necrotizing injury and destruction from necrotizing substances.substances.

Electrical burns-Electrical burns-results from results from coagulation necrosis that is caused by coagulation necrosis that is caused by intense heat from an electrical currentintense heat from an electrical current

Smoke & inhalation injury-Smoke & inhalation injury-inhaling inhaling hot air or noxious chemicalshot air or noxious chemicals

Cold thermal injury-Cold thermal injury-frostbite.frostbite.


Referral CriteriaReferral Criteria

22ndnd or 3 or 3rdrd Degree Burns >10% BSA Degree Burns >10% BSA Burns to Face, Hands , Feet, Burns to Face, Hands , Feet,

Genitailia, Perineum, or major Joints. Genitailia, Perineum, or major Joints. ESPECIALY CIRCUMFRENTIAL BURNSESPECIALY CIRCUMFRENTIAL BURNS

Electrical Burns Electrical Burns Chemical BurnsChemical Burns Inhalation InjuryInhalation Injury


Referral CriteriaReferral Criteria

Burns with pre-existing PMHX that Burns with pre-existing PMHX that could complicate recoverycould complicate recovery

Concomitant trauma (If Major Concomitant trauma (If Major Trauma, The Trauma Center , Not the Trauma, The Trauma Center , Not the Burn Center should be the initial Burn Center should be the initial stabilizing unit)stabilizing unit)

When in doubt , consult with a burn When in doubt , consult with a burn centercenter


Thermal BurnsThermal Burns

most common typemost common type result from residential fires, result from residential fires,

automobile accidents, playing with automobile accidents, playing with matches, improperly stored gasoline, matches, improperly stored gasoline, space heaters, electrical malfunctions, space heaters, electrical malfunctions, or arsonor arson

inhaling smoke, steam, dry heat (fire), inhaling smoke, steam, dry heat (fire), wet heat (steam), radiation, sun, etc...wet heat (steam), radiation, sun, etc...


Chemical BurnChemical Burn

2 types of chemical burns2 types of chemical burns acids-acids-can be neutralizedcan be neutralized alkalinealkaline- adheres to tissue, - adheres to tissue,

causing causing protein hydrolyses protein hydrolyses and liquefactionand liquefaction examples: cleaning agents, drain examples: cleaning agents, drain

cleaners, and lyes, etc...cleaners, and lyes, etc...


Chemical BurnChemical Burn

Different types Different types of burnsof burns

1 Outer skin layer1 Outer skin layer2 Middle skin layer2 Middle skin layer3 Deep skin layer3 Deep skin layer4 First degree burn4 First degree burn5 Second degree 5 Second degree burnburn6 Third degree 6 Third degree burnburn


Remember….Remember….

With chemical burns, tissue With chemical burns, tissue destruction may continue for up to destruction may continue for up to 72 hours afterwards.72 hours afterwards.

It is important to remove the person It is important to remove the person from the burning agent or vice versa.from the burning agent or vice versa.

The latter is accomplished by The latter is accomplished by lavaging the affected area with lavaging the affected area with copious amounts of water.copious amounts of water.


Smoke and Inhalation Smoke and Inhalation InjuryInjury

Can damage the tissues of the Can damage the tissues of the respiratory tractrespiratory tract

Although damage to the respiratory Although damage to the respiratory mucosa can occur, it seldom mucosa can occur, it seldom happens because the vocal cords happens because the vocal cords and glottis closes as a protective and glottis closes as a protective mechanisms.mechanisms.


3 types of smoke and 3 types of smoke and inhalation injuriesinhalation injuries

1. 1. Carbon monoxide poisoningCarbon monoxide poisoning (CO poisoning and asphyxiation (CO poisoning and asphyxiation count for majority of deaths)count for majority of deaths)

Treatment- 100% humidified oxygen-Treatment- 100% humidified oxygen-draw carboxyhemoglobin level- can draw carboxyhemoglobin level- can occur without any burn injury to the skinoccur without any burn injury to the skin


2. 2. Inhalation injury above the Inhalation injury above the glottisglottis (caused by inhaling hot air, (caused by inhaling hot air, steam, or smoke.)steam, or smoke.) Mechanical obstruction can occur Mechanical obstruction can occur

quickly-True ER! Watch for facial quickly-True ER! Watch for facial burns, signed nasal hair, hoarseness, burns, signed nasal hair, hoarseness, painful swallowing, and darkened oral painful swallowing, and darkened oral or nasal membranesor nasal membranes


33. Inhalation injury below . Inhalation injury below glottisglottis (above glottis-injury is thermally (above glottis-injury is thermally

produced)produced) below glottis-it is usually chemically below glottis-it is usually chemically

produced.produced. Amount of damage related to length Amount of damage related to length

of exposure to smoke or toxic fumesof exposure to smoke or toxic fumes Can appear 12-24 hours after burn Can appear 12-24 hours after burn


ELECTRICAL BURNSELECTRICAL BURNS

Injury from Injury from electrical burns electrical burns results from results from coagulation coagulation necrosis that is necrosis that is caused by intense caused by intense heat generated heat generated from an electric from an electric current.current.


Electrical BurnsElectrical Burns

Can cause tissue anoxia and deathCan cause tissue anoxia and death The severity depends on amount of The severity depends on amount of

voltage, tissue resistance, current voltage, tissue resistance, current pathways, and surface area in pathways, and surface area in contact with the current and length contact with the current and length of time the current flow was of time the current flow was sustained.sustained.


Electrical injury can Electrical injury can cause:cause:

Fractures of long bones and vertebraFractures of long bones and vertebra Cardiac arrest or arrhythmias--can be Cardiac arrest or arrhythmias--can be

delayed 24-48 hours after injurydelayed 24-48 hours after injury Severe metabolic acidosis--can Severe metabolic acidosis--can

develop in minutesdevelop in minutes Myoglobinuria--acute renal tubular Myoglobinuria--acute renal tubular

necrosis- myoglobin released from necrosis- myoglobin released from muscle tissue whenever massive muscle tissue whenever massive muscle damage occurs--goes to muscle damage occurs--goes to kidneys--and can mechanically block kidneys--and can mechanically block the renal tubules due to the large size!the renal tubules due to the large size!














Treatment of electrical Treatment of electrical burns…burns…

Fluids--Ringers lactate or other fluids-Fluids--Ringers lactate or other fluids-flushes out kidneys--you want 75-100 flushes out kidneys--you want 75-100 cc/hr until urine sample clear cc/hr until urine sample clear

an osmotic diuretic (Mannitol) may an osmotic diuretic (Mannitol) may be given to maintain urine outputbe given to maintain urine output


Cold Thermal Injury Cold Thermal Injury (Frostbite)(Frostbite)

Can be localized such as frostbiteCan be localized such as frostbite systemic (hypothermia)systemic (hypothermia)


Classification of Burn Classification of Burn InjuryInjury

Treatment of burns is directly related Treatment of burns is directly related to the severity of injury!to the severity of injury!

Severity is determined by:Severity is determined by: depth of burndepth of burn external of burn calculated in percent of external of burn calculated in percent of

total body surface (TBSA)total body surface (TBSA) location of burnlocation of burn patient risk factorspatient risk factors



DEPTH OF BURNSDEPTH OF BURNS Burn injury involves the destruction Burn injury involves the destruction

of the integumentary system.of the integumentary system. What is the function of the What is the function of the

integumentary system?integumentary system? ProtectiveProtective holds in fluids and electrolyesholds in fluids and electrolyes regulates heatregulates heat keeps harmful agents from injuring or keeps harmful agents from injuring or

invading the bodyinvading the body


Burns are defined by...Burns are defined by...

Were defined by degrees in the past! Were defined by degrees in the past! First, second, and third degreeFirst, second, and third degree

2 common guidelines now used are 2 common guidelines now used are the:the: Lund-Browder ChartLund-Browder Chart Rule of NinesRule of Nines


Rule of NinesRule of Nines In the adult, most In the adult, most

areas of the body areas of the body can be divided can be divided

roughly into portions roughly into portions of 9%, or multiples of 9%, or multiples of 9. This division, of 9. This division,

called the rule of called the rule of nines, is useful in nines, is useful in

estimating the estimating the percentage of body percentage of body surface damage an surface damage an

individual has individual has sustained in burn.sustained in burn.

In small In small children, children,

relatively more relatively more area is taken up area is taken up by the head and by the head and

less by the lower less by the lower extremities. extremities.

Accordingly, the Accordingly, the rule of nines is rule of nines is

modified. In modified. In each case, the each case, the

rule gives a rule gives a useful useful

approximation of approximation of body surface.body surface.


Rules of NinesRules of Nines


Location of BurnsLocation of Burns

Has a direct relationship to the Has a direct relationship to the severity of the burn.severity of the burn.

Face, neck & chest burns may inhibit Face, neck & chest burns may inhibit respiratory illness RT mechanical respiratory illness RT mechanical obstruction secondary to edema or obstruction secondary to edema or eschar formationeschar formation


Complicating or Co-Complicating or Co-Morbid FactorsMorbid Factors

Associated TraumaAssociated Trauma Inhalation InjuriesInhalation Injuries Circumferential BurnsCircumferential Burns ElectricityElectricity Age (Young or Old)Age (Young or Old) Pre-Existing DiseasePre-Existing Disease AbuseAbuse


3 Phases of Burn 3 Phases of Burn ManagementManagement

emergent emergent (resuscitative)(resuscitative)

acuteacuterehabilitativerehabilitative


Pre-hospital CarePre-hospital Care Remove from area! Stop the burn!Remove from area! Stop the burn! If thermal burn is large--If thermal burn is large--FOCUS on FOCUS on

the ABC’sthe ABC’s A=airway-A=airway-check for patency, soot check for patency, soot

around nares, or signed nasal hairaround nares, or signed nasal hair B=breathingB=breathing- check for adequacy of - check for adequacy of

ventilationventilation C=circulation-C=circulation-check for presence and check for presence and

regularity of pulsesregularity of pulses


Other precautions...Other precautions...

Burn too large--don’t immerse in Burn too large--don’t immerse in water due to extensive heat losswater due to extensive heat loss

Never pack in iceNever pack in ice Pt. should be wrapped in dry clean Pt. should be wrapped in dry clean

material to decrease contamination material to decrease contamination of wound and increase warmthof wound and increase warmth


Emergent PhaseEmergent Phase (Resuscitative Phase) (Resuscitative Phase)

Lasts from onset to 5 or more days Lasts from onset to 5 or more days but usually lasts 24-48 hoursbut usually lasts 24-48 hours

begins with fluid loss and edema begins with fluid loss and edema formation and continues until fluid formation and continues until fluid motorization and diuresis beginsmotorization and diuresis begins

Greatest initial threat is Greatest initial threat is hypovolemic shock to a major hypovolemic shock to a major burn patient!burn patient!


Complications during Complications during emergent phase of burn emergent phase of burn injury are 3 major organ injury are 3 major organ

systems...systems...CardiovascularCardiovascularRespiratoryRespiratoryRenal systemsRenal systems


Cardiovascular SystemsCardiovascular Systems Arrhythmias, hypovolemic shock which may lead Arrhythmias, hypovolemic shock which may lead

to irreversible shockto irreversible shock circulation to limbs can be impaired by circulation to limbs can be impaired by

circumferential burns and then the edema circumferential burns and then the edema formationformation

Causes: occluded blood supply thus causing Causes: occluded blood supply thus causing ischemia, necrosis, and eventually gangrene.ischemia, necrosis, and eventually gangrene.

Escharotomies (incisions through eschar) done to Escharotomies (incisions through eschar) done to restore circulation to compromised extremities.restore circulation to compromised extremities.


Respiratory SystemRespiratory System Vulnerable to 2 types of injuryVulnerable to 2 types of injury

1. 1. Upper airway burnsUpper airway burns that cause edema that cause edema formation & obstruction of the airwayformation & obstruction of the airway

2. Inhalation injury2. Inhalation injury can show up 24 hrs can show up 24 hrs later-watch for resp. distress such as later-watch for resp. distress such as increased agitation or change in rate or increased agitation or change in rate or character of resp.character of resp.

preexisting problem (ex. COPD) more prone preexisting problem (ex. COPD) more prone to get resp. infectionto get resp. infection

Pneumonia is common complication of major burnsPneumonia is common complication of major burns Is possible to overload with fluids--leading to Is possible to overload with fluids--leading to

pulmonary edemapulmonary edema


Renal SystemRenal System

Most common renal complication of Most common renal complication of burns in the emergent phase is burns in the emergent phase is ATN.ATN. Because of hypovolemic state, blood Because of hypovolemic state, blood flow decreases, causing renal flow decreases, causing renal ischemia. If it continues, acute renal ischemia. If it continues, acute renal failure may develop.failure may develop.


Nursing management in the Nursing management in the emergent phase is...emergent phase is...

Airway managementAirway management-early -early nasotracheal or endotracheal intubation nasotracheal or endotracheal intubation before airway is actually compromised before airway is actually compromised (usually 1-2 hours after burn)(usually 1-2 hours after burn)

ventilator? ABGs? Escharotomies?ventilator? ABGs? Escharotomies? 6-12 hours later-Bronchoscopy to assess 6-12 hours later-Bronchoscopy to assess

lower resp. tactlower resp. tact high fowler’s position-cough & deep high fowler’s position-cough & deep

breathe every hour, turn q 1-2 hrs, chest breathe every hour, turn q 1-2 hrs, chest physiotherapy, suction prnphysiotherapy, suction prn


Fluid ShiftsFluid Shifts Massive fluid shifts out of blood vessels Massive fluid shifts out of blood vessels

as a result of increased capillary as a result of increased capillary permeability. When capillary walls permeability. When capillary walls become more permeable, water, sodium, become more permeable, water, sodium, and later plasma protein (esp. albumin) and later plasma protein (esp. albumin) moves into interstitial spaces & other moves into interstitial spaces & other tissues. The colloidal osmotic pressure tissues. The colloidal osmotic pressure decreases with loss of protein from the decreases with loss of protein from the vascular space. This called vascular space. This called second second spacing.spacing.


Third SpacingThird Spacing

Fluids goes into areas with no fluids and Fluids goes into areas with no fluids and this is called third spacing. Examples of this is called third spacing. Examples of third spacing are exudate and blister third spacing are exudate and blister formation.formation.

Net result is decreased volume, Net result is decreased volume, depletion due to fluid shifts = edema, depletion due to fluid shifts = edema, decreased blood pressure, and increased decreased blood pressure, and increased pulsepulse


Hypovolemic ShockHypovolemic Shock

Occurs when there is a loss of Occurs when there is a loss of intravascular fluid volume. The intravascular fluid volume. The volume is inadequate to fill vascular volume is inadequate to fill vascular space and is unavailable for space and is unavailable for circulation.circulation.

Also, burns have a direct loss of fluid Also, burns have a direct loss of fluid due to evaporation.due to evaporation.


Inflammation & HealingInflammation & Healing

Burn injuries casue coagulation Burn injuries casue coagulation necrosis whereby tissues and vessels necrosis whereby tissues and vessels are damaged or destroyedare damaged or destroyed

Wound repair begins within the first Wound repair begins within the first 6-12 hours after injury.6-12 hours after injury.


Immunologic ChangesImmunologic Changes

Are caused by burns.Are caused by burns. Skin barrier destroyed and all Skin barrier destroyed and all

changes make the burn patient more changes make the burn patient more susceptible to infectionsusceptible to infection

Pt may be in shock from pain and Pt may be in shock from pain and hypovolemia.hypovolemia.


Other factors to Other factors to consider...consider...

Full-thickness burns and deep partial Full-thickness burns and deep partial thickness burns are initially thickness burns are initially anesthetic because nerve endings anesthetic because nerve endings are destroyed.are destroyed.

Superficial to moderate partial Superficial to moderate partial thickness burns are very painful. thickness burns are very painful. Why?Why?


Still more factors to Still more factors to consider...consider... Severe dehydration is possible even though Severe dehydration is possible even though

the patient maybe edematous--the patient maybe edematous--Why?Why? May have an dynamic ileus RT body’s May have an dynamic ileus RT body’s

response to massive trauma and potassium response to massive trauma and potassium shiftsshifts--Why?--Why?

Shivering due to chilling caused by heat Shivering due to chilling caused by heat loss, anxiety, and painloss, anxiety, and pain

unable to recall events RT hypoxia unable to recall events RT hypoxia associated with smoke inhalation, or head associated with smoke inhalation, or head trauma or overdose of sedatives or pain trauma or overdose of sedatives or pain medsmeds


Fluid TherapyFluid Therapy 1 or 2 large bore IV replacement lines (may 1 or 2 large bore IV replacement lines (may

need jugular or subclavian)need jugular or subclavian) Cutdown rare RT increased risk of infection & Cutdown rare RT increased risk of infection &

sepsissepsis Fluid replacement based on: size/depth of Fluid replacement based on: size/depth of

burn, age of pt., & individualized burn, age of pt., & individualized considerations--ex. Dehydration in preburn considerations--ex. Dehydration in preburn state, chronic illnessstate, chronic illness

options- RL, D5NS, dextam, albumin, etc.options- RL, D5NS, dextam, albumin, etc. there are formula’s for replacement: Parkland there are formula’s for replacement: Parkland

formula and Brooke formulaformula and Brooke formula


Assessment of adequacy Assessment of adequacy of fluid replacementof fluid replacement

Urinary output is most commonly used Urinary output is most commonly used parameterparameter

urine OP-30-50 cc/hr in an adulturine OP-30-50 cc/hr in an adult cardiopulmonary factors- BP (systolic 90-100 cardiopulmonary factors- BP (systolic 90-100

mmHg, pulse less than 100, resp 16-20 mmHg, pulse less than 100, resp 16-20 breaths per min. (BP more accurate with breaths per min. (BP more accurate with arterial line)arterial line)

sensoruim-alert, oriented to time, place, & sensoruim-alert, oriented to time, place, & personperson


Wound Care for BurnsWound Care for Burns

Can wait until patent airway, Can wait until patent airway, adequate circulation, fluid adequate circulation, fluid replacement is in place!replacement is in place!


Full-thickness burns areFull-thickness burns are

Will be dry and waxy white to dark Will be dry and waxy white to dark brown brown

will have little to no sensation will have little to no sensation because nerve endings have been because nerve endings have been destroyeddestroyed


Partial thickness burnsPartial thickness burns

Are pink to cherry red, wet, shiny Are pink to cherry red, wet, shiny with serous exudatewith serous exudate

May or may not have intact blisters May or may not have intact blisters and are very painful when touched or and are very painful when touched or exposed to airexposed to air


Cleansing and Cleansing and DebridementDebridement

Can be done in tank, shower, or bedCan be done in tank, shower, or bed Debridement may be done in Debridement may be done in

surgery. (Loose necrotic skin is surgery. (Loose necrotic skin is removed)removed)

bath given with with surgical bath given with with surgical detergent, disinfectant, or cleansing detergent, disinfectant, or cleansing agent to reduce pathogenic agent to reduce pathogenic organismsorganisms


Infection is the most Infection is the most serious threat to further serious threat to further

tissue injury and tissue injury and possible sepsis.possible sepsis.

SURVIVAL is related to prevention of SURVIVAL is related to prevention of wound contamination.wound contamination. Source of infection is pt’s own flora, Source of infection is pt’s own flora,

predominantly from the skin, resp. predominantly from the skin, resp. tract, and GI tract. tract, and GI tract.

Prevention of cross contamination from Prevention of cross contamination from other patients is the priority for nurses!other patients is the priority for nurses!


2 methods used to 2 methods used to control infections in burn control infections in burn

wounds...wounds... Open methodOpen method- pt’s burn is covered - pt’s burn is covered

wit ha topical antibiotic and has no wit ha topical antibiotic and has no dressingdressing

Closed method-Closed method-uses sterile gauze uses sterile gauze impregnated with or laid over a impregnated with or laid over a topical antibiotic. Dressings changed topical antibiotic. Dressings changed 2-3 times q 24 hrs.2-3 times q 24 hrs.


Wound Care continued...Wound Care continued...

Staff should wear disposable hats, gowns, Staff should wear disposable hats, gowns, gloves, masks when wounds are exposedgloves, masks when wounds are exposed

appropriate use of sterile vs. nonsterile appropriate use of sterile vs. nonsterile techniquestechniques

keep room warmkeep room warm careful handwashingcareful handwashing any bathing areas disinfected before and any bathing areas disinfected before and

after bathingafter bathing


Coverage is the primary goal for burn Coverage is the primary goal for burn wounds. Since usually not enough wounds. Since usually not enough unburned skin for immediate skin unburned skin for immediate skin grafting, other temporary wound grafting, other temporary wound closure methods are usedclosure methods are used Allograph or homograft (same species Allograph or homograft (same species

which is usually from cadavers) is used for which is usually from cadavers) is used for wound closure-- temporary--3 days to 2 wkswound closure-- temporary--3 days to 2 wks

Porcine skin-heterograft or xenograft Porcine skin-heterograft or xenograft (different species)--temporary--3 days to 2 (different species)--temporary--3 days to 2 wkswks

autograft or cultured epithelial autograft- autograft or cultured epithelial autograft- (pt’s own skin and cell culture)- permanent(pt’s own skin and cell culture)- permanent


Surgeons use a dermatome (left) Surgeons use a dermatome (left) to remove donor skin and a to remove donor skin and a

mesher (right) to put holes in it.mesher (right) to put holes in it.


Surgeons agree that no single product or Surgeons agree that no single product or technique is right for every burn technique is right for every burn situation. And so far, there's no true situation. And so far, there's no true replacement for healthy, intact skin, replacement for healthy, intact skin, which is the body's largest organ, and which is the body's largest organ, and one of the most complex. one of the most complex. It's the first It's the first line of defense against infection and line of defense against infection and dehydration, but it's more than just dehydration, but it's more than just a physical barrier. Skin also helps a physical barrier. Skin also helps control temperature, through control temperature, through adjustments of blood flow and adjustments of blood flow and evaporation of sweat. It's an evaporation of sweat. It's an important sensory organ, too. important sensory organ, too.


Other care measures Other care measures includeinclude

Face is vascular and subject to increased Face is vascular and subject to increased edema- use open method if possible to edema- use open method if possible to decrease confusion and disorientationdecrease confusion and disorientation

eye care-use saline rinses, artificial tearseye care-use saline rinses, artificial tears hands &arms-extended and elevated on hands &arms-extended and elevated on

pillows or in slings to minimize edema, pillows or in slings to minimize edema, may need splints to keep them in may need splints to keep them in functional positionsfunctional positions


Ears- keep free of pressure. Ear Ears- keep free of pressure. Ear burns-no pillows! Neck burns burns-no pillows! Neck burns should not use pillows in order to should not use pillows in order to decrease wound contraction.decrease wound contraction.

Perineum-must be kept clean & Perineum-must be kept clean & dry. Indwelling foley will help in this dry. Indwelling foley will help in this & also to provide hourly outputs.& also to provide hourly outputs.

Lab tests prn to monitor electrolyte Lab tests prn to monitor electrolyte imbalance and ABGsimbalance and ABGs

Physical therapy stared Physical therapy stared immediatelyimmediately


Drug TherapyDrug Therapy

Analgesics and SedativesAnalgesics and Sedatives given for pt comfortgiven for pt comfort IV pain meds initialy due to:IV pain meds initialy due to:

GI function is slowed or impaired GI function is slowed or impaired because of shock or paralytic ileusbecause of shock or paralytic ileus

IM injections will not be absorbed wellIM injections will not be absorbed well


Drug TherapyDrug Therapy

Tetanus immunization-Tetanus immunization- given routinely given routinely to all burn patients because of the to all burn patients because of the likelihood of anaerobic burn-wound likelihood of anaerobic burn-wound contaminationcontamination

Antimicrobial agents-Antimicrobial agents-usually topical usually topical due to little or no blood supply to the burn due to little or no blood supply to the burn eschar so little delivery of the antibiotic to eschar so little delivery of the antibiotic to woundwound

Drug of choice is: Drug of choice is: Silver sulfadiazineSilver sulfadiazine


Nutritional TherapyNutritional Therapy Fluid replacement takes priority over Fluid replacement takes priority over

nutritional needs in the initial nutritional needs in the initial emergent phase. emergent phase. Why?Why?

NG tube is inserted and connected to NG tube is inserted and connected to low intermittent suction for low intermittent suction for decompression. When bowel sounds decompression. When bowel sounds return (48-72 hrs) after injury, start return (48-72 hrs) after injury, start with clear liquids and progress up to a with clear liquids and progress up to a diet high in proteins and caloriesdiet high in proteins and calories


Burn patients need more calories & Burn patients need more calories & failure to provide will lead to delayed failure to provide will lead to delayed wound healing and malnutrition.wound healing and malnutrition.

Give calorie containing liquids instead Give calorie containing liquids instead of water due to need for calories and of water due to need for calories and potential for water intoxicationpotential for water intoxication

Enteral feedings into the duodenum Enteral feedings into the duodenum (recommended) can: reduce n&v, (recommended) can: reduce n&v, more continuous feedings, and more continuous feedings, and increase wd healing!increase wd healing!


Acute PhaseAcute Phase Begins with mobilization of Begins with mobilization of

extracellular fluid and subsequent extracellular fluid and subsequent diuresis.diuresis.

Is concluded when the burned area is Is concluded when the burned area is completely covered or when wounds completely covered or when wounds are healed. May take weeks or months.are healed. May take weeks or months.

Pt is no longer grossly edematous due Pt is no longer grossly edematous due to fluid mobilization, full & partial to fluid mobilization, full & partial thickness burns more evident, bowel thickness burns more evident, bowel sounds return, pt more aware of pain sounds return, pt more aware of pain and condition.and condition.


Healing begins when WBCs have Healing begins when WBCs have surrounded the burn and surrounded the burn and phagocytosis begins, necrotic tissue phagocytosis begins, necrotic tissue begins to slough, fibroblasts lay down begins to slough, fibroblasts lay down matrices of collagen precursors to matrices of collagen precursors to form granulation tissue.form granulation tissue.

Partial-thickness burns (if kept free Partial-thickness burns (if kept free from infections) will heal from edges from infections) will heal from edges and from below. (10-14 days)and from below. (10-14 days)

Full-thickness burns must be covered Full-thickness burns must be covered by skin grafts.by skin grafts.


Laboratory ValuesLaboratory Values Sodium-Sodium- Hyponatremia can occur due to: Hyponatremia can occur due to:

silver nitrate topical oints as a result of silver nitrate topical oints as a result of sodium loss through eshcar, hydrotherapy, sodium loss through eshcar, hydrotherapy, excessive GI drainage, diarrhea, excessive excessive GI drainage, diarrhea, excessive water intakewater intake S/S of hyponatremia: weakness, dizziness, S/S of hyponatremia: weakness, dizziness,

muscle cramps, fatigue, HA, tachycardia, & muscle cramps, fatigue, HA, tachycardia, & confusionconfusion

Hypernatremia can occur: too much Hypernatremia can occur: too much hypertonic fluids, improper tube feedings, hypertonic fluids, improper tube feedings, inappropriate fluid administrationinappropriate fluid administration S/S of hypernatremia: thirst; dried furry tongue; S/S of hypernatremia: thirst; dried furry tongue;

lethargy; confusion; and possible seizureslethargy; confusion; and possible seizures


Potassium-Potassium- hyperkalemia is note if pt is hyperkalemia is note if pt is in renal failure, adrenocortical in renal failure, adrenocortical insufficiency, or massive deep muscle insufficiency, or massive deep muscle injury with lg. amts. of potassium released injury with lg. amts. of potassium released from damaged cells. Cardiac arrhythmias from damaged cells. Cardiac arrhythmias and ventricular failure can occur if K+ and ventricular failure can occur if K+ level greater >7mEq/L. muscle weakness level greater >7mEq/L. muscle weakness & EKG changes are noted.& EKG changes are noted. Hypokalemia is noted with silver nitrate Hypokalemia is noted with silver nitrate

therapy and long hydrotherapy. Other causes: therapy and long hydrotherapy. Other causes: vomiting, diarrhea, prolonged GI suction, vomiting, diarrhea, prolonged GI suction, prolonged IV therapy without K+ prolonged IV therapy without K+ supplementation. Constant K+ losses occur supplementation. Constant K+ losses occur through the burn wound.through the burn wound.


Complications of Acute Complications of Acute PhasePhase Infection-Infection- due to destruction of body’s 1st due to destruction of body’s 1st

line of defense. Partial thickness wds can line of defense. Partial thickness wds can convert to full-thickness wds with infection convert to full-thickness wds with infection present. Pt may get sepsis from wound present. Pt may get sepsis from wound infections. Signs of sepsis are: high temp., infections. Signs of sepsis are: high temp., increased pulse & resp., decreased BP, and increased pulse & resp., decreased BP, and decreased urinary output, mild confusion, decreased urinary output, mild confusion, chills, malaise, and loss of appetite. WBC bet. chills, malaise, and loss of appetite. WBC bet. 10,000 and 20,000. Infections usually gram 10,000 and 20,000. Infections usually gram neg. bacteria (pseudomonas, proteus)neg. bacteria (pseudomonas, proteus)

Obtain cultures from all possible sources: IV, Obtain cultures from all possible sources: IV, foley, wound, oropharynx, and sputumfoley, wound, oropharynx, and sputum


Cardiovascular-Cardiovascular- same as in emergent phase same as in emergent phase Neurologic-Neurologic-possible from electrical injuriespossible from electrical injuries Musculoskeletal-Musculoskeletal-has the most potential for has the most potential for

complications during acute phase due to complications during acute phase due to healing and scar formation making skin less healing and scar formation making skin less supple and pliant. ROM limited, contractures supple and pliant. ROM limited, contractures can occurcan occur

Gastrointestinal-Gastrointestinal-adynamic ileus results from adynamic ileus results from sepsis, diarrhea or constipation (RT narcotics sepsis, diarrhea or constipation (RT narcotics & decreased mobility), gastric ulcers RT & decreased mobility), gastric ulcers RT stress, occult blood in stools possiblestress, occult blood in stools possible

EndocrineEndocrine-stress DM might occur-assess -stress DM might occur-assess glucose prnglucose prn


Nursing management-Nursing management-acute phaseacute phase Predominant therapeutic interventions Predominant therapeutic interventions

are:are: fluid replacement, physical therapy, wd care, fluid replacement, physical therapy, wd care,

early excision and grafting, and pain early excision and grafting, and pain managementmanagement

Fluid replacementFluid replacement continues from continues from emergent phase to acute phases--emergent phase to acute phases--given for:given for: fluid losses, administer medications, & for fluid losses, administer medications, & for transfusions.transfusions.

Physical therapy-Physical therapy- to maintain optimal joint to maintain optimal joint functionfunction

Pain management- Pain management- most critical functions most critical functions as a nurse.as a nurse.

Nutritional therapy-Nutritional therapy-provide adequate provide adequate proteins & caloriesproteins & calories


Wound Care- Wound Care- the goals are cleanse and the goals are cleanse and debride the area of necrotic tissue &debris, debride the area of necrotic tissue &debris, minimize further damage to viable skin, minimize further damage to viable skin, promote patient comfort, & reepithelialization promote patient comfort, & reepithelialization or success with skin grafting.or success with skin grafting.

Care for donor site and other grafts Care for donor site and other grafts necessarynecessary

Excision and grafting-Excision and grafting-eschar removed to eschar removed to subcutaneous tissue or fascia, graft applied subcutaneous tissue or fascia, graft applied to tissueto tissue Cultured epithelial autograft (CEA)uses patient’s Cultured epithelial autograft (CEA)uses patient’s

own cells to grow skin-permanentown cells to grow skin-permanent artificial skin is the latest trend. Examples: artificial skin is the latest trend. Examples:

Alloderm, Life-Skin, etc.Alloderm, Life-Skin, etc.


Rehabilitation PhaseRehabilitation Phase Defined as beginning when the patient’s Defined as beginning when the patient’s

burn wound is covered with skin or burn wound is covered with skin or healed and patient is capable of healed and patient is capable of assuming some self-care activity. assuming some self-care activity.

Can occur as early as 2 weeks to as long Can occur as early as 2 weeks to as long as 2-3 months after the burn injuryas 2-3 months after the burn injury

Goals for this time is to assist patient in Goals for this time is to assist patient in resuming functional role in society & resuming functional role in society & accomplish functional and cosmetic accomplish functional and cosmetic reconstruction.reconstruction.


Clinical ManifestationsClinical Manifestations

Burn wd either heals by primary Burn wd either heals by primary intention or by grafting.intention or by grafting.

Scars may form & contractures.Scars may form & contractures. Mature healing is reached in 6 Mature healing is reached in 6

months to 2 years months to 2 years Avoid direct sunlight for 1 year on Avoid direct sunlight for 1 year on

burn burn new skin sensitive to traumanew skin sensitive to trauma


ComplicationsComplications

Most common complications of burn Most common complications of burn injury are skin and joint contractures injury are skin and joint contractures and hypertrophic scarringand hypertrophic scarring

Because of pain, pts will assume Because of pain, pts will assume flexed position. It predisposes wds to flexed position. It predisposes wds to contracture formationcontracture formation

Use of physical therapy, pressure Use of physical therapy, pressure garments, splints, etc. are usedgarments, splints, etc. are used


Nursing management Nursing management during rehabilitation during rehabilitation

phasephase Must be directed to returning patient Must be directed to returning patient

to society, address emotional to society, address emotional concerns, spiritual and cultural concerns, spiritual and cultural needs, self-esteem, teaching of needs, self-esteem, teaching of wound care management, nutrition, wound care management, nutrition, role of exercises and physical therapy role of exercises and physical therapy explained. A common emotional explained. A common emotional response seen is response seen is regression.regression.


Special needs of the Special needs of the nursing staffnursing staff

The staff of burn units are prone to The staff of burn units are prone to higher rates of burn-out. The care of a higher rates of burn-out. The care of a burn patient is a long journey that the burn patient is a long journey that the patient, nurse, and significant others patient, nurse, and significant others must travel. The road to recovery is full must travel. The road to recovery is full of potential threats to the patient. of potential threats to the patient. Support services are necessary for the Support services are necessary for the medical team of any long-term burn medical team of any long-term burn patients.patients.


Care of Care of BB UU RR NN SSB - breathingB - breathing

body imagebody image

U - urine outputU - urine output

R - rule of ninesR - rule of nines

resuscitation of fluidresuscitation of fluid

N - nutritionN - nutrition

S - shockS - shock

silvadenesilvadene


B- Breathing-B- Breathing- keep airway open. keep airway open. Facial burns, singed nasal hair, Facial burns, singed nasal hair, hoarseness, sooty sputum, bloody hoarseness, sooty sputum, bloody sputum and labored respiration sputum and labored respiration indicate TROUBLE!indicate TROUBLE!

Body Image-Body Image- assist Bernie in coping by assist Bernie in coping by encouraging expression of thoughts encouraging expression of thoughts and feelings.and feelings.


U- URINE OUTPUT-U- URINE OUTPUT- in an in an adult, urine output should adult, urine output should be 30-70 cc per hour, in the be 30-70 cc per hour, in the child 20-50 cc per hour, and child 20-50 cc per hour, and in the infant, 10-20 cc per in the infant, 10-20 cc per hour. Watch the K+ to keep hour. Watch the K+ to keep it between 3.5-5.0 mEq/L. it between 3.5-5.0 mEq/L. Keep the CVP around 12 cm Keep the CVP around 12 cm water pressure!water pressure!


R- RESUSCITATION OF FLUID-R- RESUSCITATION OF FLUID- Salt Salt & electrolyte solutions are essential & electrolyte solutions are essential over the 1over the 1stst 24 hours. Maintain B/P at 24 hours. Maintain B/P at 90-100 systolic. ½ of the fluid for the 90-100 systolic. ½ of the fluid for the first 24 hrs should be administered first 24 hrs should be administered over the first 8 hour period, then the over the first 8 hour period, then the remainder is administered over the remainder is administered over the next 16 hours. First 24 hour next 16 hours. First 24 hour calculation starts at the time of calculation starts at the time of injury.injury.

RULE OF NINE’S-RULE OF NINE’S- used for adults to used for adults to determine burn surface area!determine burn surface area!


N-NUTRITION-N-NUTRITION- protein & protein & calories are components of calories are components of the diet! Supplemental the diet! Supplemental gastric tube feedings or gastric tube feedings or hyperalimentation may be hyperalimentation may be used in pts with large used in pts with large burned areas. Daily weights burned areas. Daily weights will assist in evaluating the will assist in evaluating the nutritional needs!nutritional needs!


S-SHOCK-S-SHOCK- Watch the B/P, Watch the B/P, CVP, and renal function.CVP, and renal function.

Silvadene-Silvadene-for infection.for infection.

REMEMBER THESE PEOPLE REMEMBER THESE PEOPLE ARE AFRAID AND NEED ARE AFRAID AND NEED SUPPORT!!!!!SUPPORT!!!!!


Burn Wound InfectionBurn Wound Infection An ability to make the diagnosis of burn wound infection is important. A An ability to make the diagnosis of burn wound infection is important. A

clinically focused set of burn wound infection definitions has recently been clinically focused set of burn wound infection definitions has recently been published and is summarized as follows:published and is summarized as follows:

Burn impetigoBurn impetigo Diagnostic points - Loss of epithelium from previously epithelialized surface; not Diagnostic points - Loss of epithelium from previously epithelialized surface; not

related to local traumarelated to local trauma Treatment strategies - Regular cleaning of debris and exudate; topical Treatment strategies - Regular cleaning of debris and exudate; topical

antistaphylococcal antibiotics; grafting of chronically unstable areas of epitheliumantistaphylococcal antibiotics; grafting of chronically unstable areas of epithelium Burn-related surgical wound infectionBurn-related surgical wound infection

Diagnostic points - Infection in surgically created would that has not yet Diagnostic points - Infection in surgically created would that has not yet epithelialized; includes loss of any overlying graft or membraneepithelialized; includes loss of any overlying graft or membrane

Treatment strategies - Regular cleaning of debris and exudate; systemic and Treatment strategies - Regular cleaning of debris and exudate; systemic and topical antistaphylococcal antibiotics; grafting of chronically unstable areas of topical antistaphylococcal antibiotics; grafting of chronically unstable areas of epitheliumepithelium

Burn wound cellulitisBurn wound cellulitis Diagnostic points - Infection occurs in uninjured skin surrounding a wound; signs of Diagnostic points - Infection occurs in uninjured skin surrounding a wound; signs of

local infection progress beyond what is expected from burn-related inflammationlocal infection progress beyond what is expected from burn-related inflammation Treatment strategies - Systemic antibiotics directed against Treatment strategies - Systemic antibiotics directed against Streptococcus Streptococcus

pyogenes;pyogenes; proper treatment of primary wound proper treatment of primary wound Invasive burn wound infectionInvasive burn wound infection

Diagnostic points - Infection occurs in unexcised burn and invades viable Diagnostic points - Infection occurs in unexcised burn and invades viable underlying tissue; diagnosis may be supported by results from histologic underlying tissue; diagnosis may be supported by results from histologic examination or quantitative cultureexamination or quantitative culture

Treatment strategies - Systemic antibiotics directed against presumed pathogen; Treatment strategies - Systemic antibiotics directed against presumed pathogen; wound excision, with biologic closure when possiblewound excision, with biologic closure when possible


Outpatient wound care strategiesOutpatient wound care strategies Components of outpatient burn care include Components of outpatient burn care include

the following:the following:

Patient and family educationPatient and family education Wound cleansingWound cleansing Choice of topical or membrane dressingChoice of topical or membrane dressing Pain controlPain control Early return instructionsEarly return instructions Follow-up clinic visitsFollow-up clinic visits Long-term follow-up careLong-term follow-up care


s:s: First-degree burns are usually red, dry, and painful. Burns First-degree burns are usually red, dry, and painful. Burns

initially termed first-degree are often actually superficial initially termed first-degree are often actually superficial second-degree burns, with sloughing occurring the next day.second-degree burns, with sloughing occurring the next day.

Second-degree burns are often red, wet, and very painful. Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form Their depth, ability to heal, and propensity to form hypertrophic scars (see hypertrophic scars (see Media file 2) vary enormously.) vary enormously.

Third-degree burns are generally leathery in consistency, Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration, with except by contraction and limited epithelial migration, with resulting hypertrophic and unstable cover (see resulting hypertrophic and unstable cover (see Media file 3). ). Burn blisters (see Burn blisters (see Media file 4) can overlie both second- and ) can overlie both second- and third-degree burns. The management of burn blisters third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly with remains controversial, yet intact blisters help greatly with pain control. Debride blisters if infection occurs.pain control. Debride blisters if infection occurs.

Fourth-degree burns involve underlying subcutaneous Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced tissue, tendon, or bone. Usually, even an experienced examiner has difficulty accurately determining burn depth examiner has difficulty accurately determining burn depth during early examination. As a general rule, burn depth is during early examination. As a general rule, burn depth is underestimated upon initial examination.underestimated upon initial examination.

http://emedicine.medscape.com/article/435402-media




Wound dressing, whether one is using Wound dressing, whether one is using topical medication or a wound topical medication or a wound membrane, should provide 4 membrane, should provide 4 benefits, including (1) benefits, including (1) prevention of wound desiccation, prevention of wound desiccation, (2) control of pain, (2) control of pain, (3) reduction of wound (3) reduction of wound colonization and infection, and colonization and infection, and (4) (4) prevention of added trauma to the prevention of added trauma to the wound wound


Elaborate specific conditions may Elaborate specific conditions may mandate an early return to the mandate an early return to the hospital. Particularly important are hospital. Particularly important are (1) (1) pain and anxiety associated with pain and anxiety associated with wound care to the degree that wound wound care to the degree that wound care is compromised, care is compromised, (2) signs of (2) signs of infection, or infection, or (3) a wound that appears deeper than (3) a wound that appears deeper than appreciated during the initial appreciated during the initial examination. Review wound care examination. Review wound care instructions with caregivers. instructions with caregivers.


Education

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