burn lecture m. catherine hough rn, ph.d university of north florida college of health department of...

BURN LECTURE

M. Catherine Hough RN, Ph.D

University of North FloridaCollege of Health

Department of Nursing

REVIEW OF SKIN FUNCTIONS

• Functions of the Skin– Protection– Heat Regulation– Sensory perception– Excretion– Vitamin D Production– Expression

Cross section of Skin

CLASSIFIATION OF BURNSRx of burn is R/T the severity of the burn -

severity is determined by:• depth of the burn• extent o the burn (% of total body surface area

(TBSA)• location of the burn• patients risk factors

CLASSIFIATION OF BURNS...

• Partial Thickness - characterized by varying depth from epidermis (outer layer of skin) to the dermis (middle layer of the skin)– Superficial - includes only the epidermis (First Degree)– Deep - involves entire epidermis and part of the dermis

(Second Degree)

• Full Thickness - includes destruction of the epidermis and– the entire dermis as well as possible damage to the SQ, muscle and bone

(Third and Fourth Degree)

Classification…

• Clinical Appearance – Superficial – 1st degree– Erythema, blanching on pressure, pain & mild swelling, no vesicles or

blisters (although after 24 hours the skin may blister and peel

• Clinical Appearance – Deep – 2nd degree– Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured),

severe pain caused by nerve injury, mid-to-moderate edema

• Clinical Appearance – Full-thickness – 3rd degree– Dry, waxy, leathery, or hard skin, visible thrombosed vessels,

insensitivity to pain and pressure of nerve distruction, possible involvement of muscles, bone and tendons.

MINOR BURNS

• < 10% of BSA of Partial Thickness Burn

• < 2% of BSA of a Full Thickness Burn

MODERATE BURNS

• 15-25 % of BSA of Partial Thickness Burn

• <10% of BSA of a Full Thickness Burn

MAJOR BURNS

• > 25% of BSA of a partial thickness

• > 10% of BSA of a full thickness

• Age > 65 or < 2

Lund-Bowder Chart

Rule of Nines

Types of Burns

• Thermal Burns• Chemical• Electrical• Inhalation• Radiation

PERIODS OF TREATMENT

• Emergent• Acute• Rehabilitation

STAGES OF BURNS

Hypovolemic Stage - begins @ onset of burn and lasts for the first 48 hours

– Rapid fluid shifts - from the vascular compartments into the interstitial spaces

– Capillary permeability with burns increases with vasodilation fluid loss deep in wounds (initially sodium and H2O then

protein loss) Hemoconcentration - Hct increases – Low blood volume, oliguria– Hyponatremia - loss of sodium and fluid– Hperkalemia - damaged cells release K+, oliguria– Metabolic acidosis

STAGES OF BURNS ...

Diuretic Stage - begins @ 48 - 72 hours after burn injury

• Capillary membrane integrity returns• Edema fluid shifts back into vessels - blood volume increases• Increase in renal blood flow - result in diuresis (unless renal damage)• Hemodilution - low Hct, decreased potassium as it moves back into

the cell or is excreted in urine with the diuresis• Fluid overload can occur due to increased intravascular volume• Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism

I. EMERGENT PERIOD

• First 24 - 48 hours • Maintain airway, fluids, analgesia, temperature,

wound

• Assessment:–Objective: how burn occurred, when, duration,

type of agent – Subjective: previous medical problems, size and

depth of burn, age, body part involved, mechanism of injury

EMERGENT PERIOD ...

Factors determining severity of burns: • size of burn • depth of burn • age• body part effected• mechanism of injury• history of cardiac, pulmonary, renal, or hepatic diseases • injuries sustained @ time of burns• duration of contact with burning agent• size & depth of burn • “Rule of Nines”

NURSING DIAGNOSIS

• Airway clearance• Ineffective fluid volume (deficit or excess)• Hypothermia• High risk for pain (with partial thickness burns)• Skin integrity, impaired• Anxiety• Knowledge deficit

INTERVENTIONS

• Maintain patent airway - watch for laryngeal edema– Escharotomy may be needed– 100% FiO2 mask

– intubation for inhalation is often required–may inquire emergent tracheostomy –may require ventilatory assistance

Tracheostomy to Prevent Airway Obstruction

Interventions - Fluid Therapy

• Start with two large bore IV’s – suture in place

• Jugular or subclavian line– unburned tissue– burned tissue

• Cutdown final measure

Interventions - Fluid Therapy...Fluid Replacement• Crystalloid Solutions

• NS• LR• D5%/NS

• Collid Solutions• Albumin• Dextran

Formulas to Calculate Fluid

Parkland Crystalloids LR: 4ml/kg/% burn; ½ given 1st 8hrs; ¼ given each next 8 hrs

Colloids 20-60% of calculated plasma volume

D5% in Water Amount to replace estimated evaporative losses

Brooke

Crystalloids LR: 2ml/kg/% burn; ½ given 1st 8 hrs; ½ given during next 16 hrs

Colloids 0.3 to 0.5 ml/kg/% burn

D5% in Water Amount to replace estimated evaporative losses

SIGNS OF ADEQUATE FLUID RESUSCITATION

• Clear sensorium• Pulse < 100 bpm• U/O 30-50 cc/hour• SBP > 90-100 mm Hg• Blood pH within normal range 7.35 - 7.45• Respirations 16-20

II. ACUTE PERIOD

• End of emergent period until burns heal• Focus shifts to care of wounds and prevention of

complications• Actual range of phase depends on degree and extent

of burn• Assessment:

Subjective - pain and anxietyObjective - complete assessment every 8 hours, dietary intake, motor ability, I&O, weight

NURSING DIAGNOSIS

• Skin integrity, impaired• Infection, high risk for• altered nutrition• Pain, acute (with partial thickness burns)• Fluid Volume Deficit• Anxiety• Hypothermia

Pain Control

• Morphine Sulfate 5-10 mg IV every 1-3 hours

• Combination therapy for painful procedures:– Diprivan– Valium– Haldol– Versed– …

NURSING DIAGNOSIS ...

• Impaired skin integrity R/T thermal injury• Coping, ineffective individual/family• Body Image Disturbance• Altered nutrition: less than body requirements R/T increased

catabolism and metabolism• Mobility, Impaired R/T pain, impaired joint movement, scar

formation• Self-care Deficit• High risk for infection R/T denuded skin, presence of pathogenic

organism, & altered immune response

INTERVENTIONS

• Releiving anxiety, denial, regression, anger, depression

• Wounds - refer to wound care • Nutrition (Nutritional assessment, pre albumin

levels, large protein requirement, carbohydrates and fats for energy, mega vitamins, TPN, enteral tube feedings any follow (~5,000 kcal/day)

• Pain - around the clock management• Prevention of infection - refer to wound care

ORGANISMS:

• Staphylococcus aureus• Pseudomonas

Infection is usually the cause of any deterioration

SIGNS OF SEPSIS:

• Change in sensorium• Fever• Tachyapnea• Paralytic ileus• Abdominal distention• Oliguria

WAYS TO PREVENT INFECTIONS:

• Gowns, masks, gloves• Sterile linen• Person with URI should not come in

contact with patient

WOUND CAREGoals:

• clean & debride the area of necrotic tissue• minimize further destruction of viable skin• promote wound re-epithelialization• promote patient comfort

WOUND CARE:

• Burn wound is unique

• Burn wound sepsis– gram +– gram (pseudomonas)– fungal (candida albicans)

WOUND CARE...• Nutrition– collagen primary structure in healing by secondary

intention– need increased protein– may need up to double the normal calorie requirements

• Inadequate blood supply• Burn wound disorders– scarring, contractures, keloids, failure to heal

WOUND CARE ...

• GOALS:

• close wound ASAP• prevent infection• reduce scarring and contractures• provide for comfort

WOUND CARE ...

• Wound cleaning: • at bed side hyrotherapy tanks, tubbing, spray

tables

• Debridement: • mechanical, surgical, enzymatic

• Topical antibacterial therapy - • sulfonamide

WOUND CARE ...

Open Technique or Exposed - more often used with burns effecting the:– face– neck– perineum– broad areas of the trunk

• Partial thickness - exudate dries in 48 to 72 hours forming a hard crust that protects the wound.

• Full thickness - dead skin is dehydrated and converted to black leathery escar in 48 to 72 hours. Loose escare is gradually removed with hydrotherapy &/or debridement

WOUND CARE ...

• Closed Technique

• Wound is washed and sterile dressings changed (may be q shift, daily)

• Dressing consists of gauze &/or ace wraps impregnated with topical ointments

WOUND CARE ...

• Semi-Openconsists of covering the wound with topical antimicrobial agents and gauze

ADVANTAGE:– speeds debridement– develops granulation tissues faster– makes skin grafting possible sooner

WOUND CARE ...

Biological Dressings:• Homeografts - same species (cadaver skin)

• temporary (3 days to 2 weeks) then body rejects

• Heterografts - another species (pig skin) • temporary coverage (3days to 2 weeks)

• Autografts - patients own skin • can be temporary or permanent coverage

• Cultured Epithelial Autographs • permanent

Wound Care - GRAFTING

• Indications for Grafting:– full thickness burns– priority areas (face)– wound bed pink firm, free of exudate– bacterial count < 100,000/gram of tissue

• Care of Grafts - assess, assess, assess

Skin Grafting

Cultured Epithelial Autografts

III. REHABILITATION PERIOD

• Care of healing skin - wash daily, cover with cocoa butter or other barrier

• Pressure garments, ace wraps - helps prevent scaring and contractures

• Promote mobility - positioning, exercise, splinting, ADL• Rehab period can last for months to even years

Primary Prevention Strategies

Safety Education: • Wear sun-screen• Fireproof your home– Install smoke alarms – check routinely– Plan emergency exits– Have regular fire drills

• Check wiring in home; safety caps on unused outlets if you have children

• Teach children safety rules for matches, fires, electrical outlets, cords, etc.