nurs 360 burns

ALTERATION IN TISSUE INTEGRITY - Burns

Nurs 360

BURNS

●Injury resulting from exposure to heat, chemicals, radiation, or electrical

●Over 1 million per year in US, mostly thermal burns

●Risk factors: ●age●smoking●alcohol/drugs●cognitive and physical disability

Types of Burns●Thermal (hot or

cold)/Scald●Chemical●Smoke

inhalation injury●Electrical●RadiationDISTURBING PICTURES

ALERT (skip to slid

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Electrical Burn

Radiation Burn

Full-Thickness Thermal Burn

Fig. 25-1. Types of burn injury. A, Full-thickness thermal burn.

Partial-Thickness Burn to the Hand

Fig. 25-1. Types of burn injury. B, Partial-thickness thermal burn.

Partial-Thickness Burns Due to Immersion in Hot Water

Fig. 25-1. Types of burn injury. C, Full-thickness scald burn secondary to immersion in hot water.

Chemical Burns●Result from tissue injury and

destruction from acids, alkalis, and organic compounds

●Alkali burns are hard to manage because they cause protein hydrolysis and liquefaction.

●Damage continues after alkali is neutralized.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology

Chemical Burns●Results in injuries to:

●Skin●Eyes●Respiratory system●Liver and kidney


Chemical Burns●Chemical should be quickly removed from the

skin.●Clothing containing the chemical should be

removed.●Tissue destruction may continue up to 72 hours

after a chemical injury.


Treatment

Smoke Inhalation Injuries

●Result from inhalation of hot air or noxious chemicals

●Cause damage to respiratory tract●Major predictor of mortality in burn

victims●Need to be treated quickly



●Three types:●Carbon monoxide poisoning

●Upper airway (above the glottis)

●Lower airway (below the glottis)Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Smoke Inhalation Injuries●Carbon monoxide (CO) poisoning

●CO is produced by the incomplete combustion of burning materials.

●Inhaled CO displaces oxygen.●Hypoxia●Carboxyhemoglobinemia●Death


https://en.wikipedia.org/wiki/Carboxyhemoglobin


●Carbon monoxide (CO) poisoning●Treat with 100% humidified oxygen.●CO poisoning may occur in the

absence of burn injury to the skin.●Skin color may be described as

“cherry red” in appearance.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Smoke Inhalation Injuries●Inhalation injury above the glottis

●Thermally produced●Hot air, steam, or smoke●Mucosal burns of oropharynx and

larynx●Mechanical obstruction can occur

quickly●True medical emergency (airway)


Smoke Inhalation Injuries●Inhalation injury above the glottis

●Reliable clues to this injury:●Presence of facial burns●Singed nasal hair●Hoarseness, painful swallowing●Darkened oral and nasal membranes●Carbonaceous sputum●History of being burned in enclosed space●Clothing burns around chest and neck



●Inhalation injury below the glottis●Injury is related to the length of

exposure to smoke or toxic fumes.●Pulmonary edema may not appear

until 12 to 24 hours after the burn.●Manifests as acute respiratory distress

syndrome (ARDS)


Types of Burn InjuryElectrical Burns

●Result from coagulation necrosis caused by intense heat generated from an electric current

●May result from direct damage to nerves and vessels, causing tissue anoxia and death


Electrical Burn: Back

Fig. 25-2. Electrical injury produces heat coagulation of blood supply and contact area as electric currentpasses through the skin. A, Back and buttock.

Electrical Burn: Leg

Fig. 25-2. Electrical injury produces heat coagulation of blood supply and contact area as electric currentpasses through the skin. B, Leg.

Severity of Burns●Source of burn●Body regions burned●Age●General health●Time●Depth/Severity●Extent

Classification of Burn Injuries●Depth

●Superficial (First degree)●Partial thickness (Second degree)●Full thickness (Third degree)

●Severity●Minor●Moderate●Major

Classification of Burn InjuryDepth of Burn

●Superficial partial-thickness burn●Involves the epidermis

●Deep partial-thickness burn●Involves the dermis

●Full-thickness burn●Involves fat, muscle, bone


Lund-Browder Chart

Fig. 25-4. A, Lund-Browder chart. By convention, areas of partial-thickness injury are colored in blue and areasof full-thickness injury in red. Superficial partial-thickness burns are not calculated.

Fig. 25-4. B, Rule of nines chart.

Rule of Nines Chart

A client received deep partial thickness burns to the ● anterior trunk● perineum● left arm anterior and posterior. Using the rule of nines, what is the percent of total body surface area (TBSA) that was burned? 28

%

Fluid Resuscitation●Parkland Formula: warmed Lactated Ringer’s

●4ml x kg x % TBSA (from rule of nines) over 24 hours●Give ½ of the total amount over the first 8 hours, ●½ of the total amount over next 16 hours

4ml x 75 kg x .28 tbsa /24 hours

4ml x 75kg x 28%tbsa = total ml over 24 hours kg 1 100% tbsa

Fluid Resuscitation●Give ½ of the total amount over the first 8 hours,

●½ of the total amount over next 16 hours1. What is the hourly rate for the first 8 hours?

4ml x 75 x .28 / 8 hours = ml /hour 2 2. What is the rate for the next 16 hours?

4ml x 75 kg x .28 tbsa /24 hours

Facial Edema Before and After Fluid Resuscitation

Fig. 25-6. A, Facial edema before fluid resuscitation. B, Facial edema after 24 hours.

Semi-disturbing picture alert

Fluid Resuscitation●Urine output is used as indicator of effectiveness● 30-50 ml/hr ●adult thermal burns

Classification of Burn InjuryLocation of Burn●Location of the burn is related to the severity of the injury●Face, neck, chest → respiratory

obstruction ●Hands, feet, joints, eyes → self-care●Ears, nose, buttocks, perineum →

infectionCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Classification of Burn InjuryLocation of Burn

●Circumferential burns of the extremities can cause circulatory compromise.

●Patients may also develop compartment syndrome.


Prehospital Care

●Electrical injuries●Remove patient from contact

with source.●Chemical injuries

●Brush solid particles off the skin.

●Use water lavage.


Prehospital Care

●Small thermal burns●Cover with clean, cool, tap

water– dampened towel. ●Large thermal burns

●Airway, breathing, and circulation


Burn Stages●Prehospital Care

●Emergent/Resuscitative Phase

●Acute Phase

●Rehabilitation Phase

Assessment and Intervention:●Ensure patent airway●Assess effectiveness of respiratory

function●Signs of respiratory burns●Prepare for early intubation●Provide high flow O2●Initiate fluid resuscitation●Indwelling urinary catheterization

Emergent PhasePathophysiology

●Fluid and electrolyte shifts (cont’d)●Normal insensible (evaporative) loss: 30 to 50

mL/hr●Severely burned patient: 200 to

400 mL/hr


Emergent PhaseComplications●Cardiovascular system

●Dysrhythmias and hypovolemic shock●Impaired circulation to extremities ●Tissue ischemia●Necrosis


Nursing Care●Assessment – continuous

●Time of Injury●Cause of Injury●First aid treatment - what was done●Past medical history●Age●Medications●Body weight

Nursing Diagnoses●Impaired gas exchange – resp compromise●Acute Pain – IV MS, propofal, wound coverage●Deficient fluid volume – IVF’s, Parkland

formula●Impaired skin integrity *Hypothermia●Risk for infection – wound management●Impaired physical mobility●Imbalanced nutrition: less than body req.●Grieving, Powerlessness, Fear

Burn Assessment & Intervention●Naso-gastric intubation●Infection prevention-protective isol.●Pain management●Tetanus administration●Monitor ABGs-serum lab work●Monitor peripheral pulses●Prevent hypothermia

Wound ManagementPain ControlAntimicrobial AgentsTetanus ProphylaxisSurgery

EscharotomySurgical debridementAutografting

Wound Management●Purpose

●Prevent sepsis●Prevent conversion of partial thickness to full●Reduce pain from exposed nerve endings●Prepare for coverage

●Dressings ●Antimicrobials – Sivadene, Sulfamylon, Silver

nitrate, Systemic antibiotics

Emergent PhaseNursing and Collaborative Management

●Drug therapy (cont’d)●Antimicrobial agents

● Topical agents● Silver sulfadiazine (Silvadene)● Mafenide acetate (Sulfamylon)

● Systemic agents are not usually used in controlling burn flora.● Initiated when diagnosis of invasive burn wound

sepsis is made


Emergent PhaseNursing and Collaborative Management

●Nutritional therapy (cont’d)●Hypermetabolic state

● Resting metabolic expenditure may be increased by 50% to 100% above normal.

● Core temperature is elevated.● Caloric needs are about 5000 kcal/day.


Wound Management●Pain control●Nutrition●Positioning, splints, exercise●Pressure garments●Appearance, scarring, future surgeries

Disturbing picture alert

Psychologic Concerns●Body image●Fear●Anxiety●Ineffective Coping●Interrupted family processes●Ineffective role performance●Grieving●Powerlessness

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