burn injury
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Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
CARE OF PATIENTS WITH BURNS
Chapter 28
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Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Burns
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Occur when there is injury to tissues of the body caused by heat, chemicals, electrical current, or radiation
Should be viewed as preventable
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Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Burns
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Epidermis (outer layer of the skin) 0.15 mm thick but thinner in older adults layer can grow back after a burn injury no blood vessels nutrients are diffused from the dermis
Dermis Thicker than epidermis contains blood vessels, sensory nerves, hair follicles,
lymph vessels, sebaceous glands and sweat glands skin cannot restore itself
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Types of Burn Injury
Dry heat Moist heat Contact Chemical Electrical burns: entry and exit site
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Types of Burn InjuryElectrical Burns
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Severity of injury depends on Amount of voltage Tissue resistance Current pathways Surface area Duration of the flow
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Types of Burn InjuryElectrical Burns
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Current that passes through vital organs will produce more life-threatening sequelae than current that passes through other tissue
Electrical sparks may ignite patients clothing, causing a combination of thermal flash injury
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Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Types of Burn InjuryElectrical Burns
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Severity of injury can be difficult to assess, as most damage occurs beneath skin Iceberg effect
Electrical current may cause muscle spasms strong enough to fracture bones
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Classification of Burn Injury
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Severity of injury is determined by Depth of burn: how deep into the skin the burn goes
Superficial: Epidermis Extent of burn in percent of TBSA( total body surface area) Location of burn Patient risk factors
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Identify the Burn DepthSuperficial/Partial Burns
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Superficial/Partial
involves the epidermis, blistering, healing is rapid 3-6 days for this injury to heal No scar formation
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Table 28-1
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Identify the Burn DepthDeep Partial Burn
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Deep Partial Burn
Deep Partial: Involves the epidermis and dermis, redness or white to skin, moderate edema
Takes 3-6 weeks to heal Scar formation does occur A few healthy cells remain
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Identify the Burn DepthFull Thickness
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Full Thickness Burns
Full Thickness: Involves the epidermis, dermis, and fat Fatty tissue and blackened skin (eschar?) can be seen May see muscle or bone involved The deeper it is, the less pain is felt: the nerve endings are
destroyed Will not heal on its own, skin and blood vessels are
destroyed Patient will require a skin graft
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Classification of Burn Injury
Extent of Burn - determined by TBSA Why is it important to know?
Determines the amount of fluids and calories the patient will need
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Classification of Burn InjuryExtent of Burn
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Two commonly used guides for determining the total body surface area Lund-Browder chart
Considered more accurate: takes age into consideration Rule of Nines
Used for initial assessment More general, quicker
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Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Rule of Nines Chart
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Know how to determine percentage of burns
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Types of Burn InjurySmoke Inhalation Injuries
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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
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Classification of Burn InjuryLocation of Burn
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Severity of burn injury is determined by location of burn wound Face, neck, chest respiratory obstruction
from inhalation of chemicals or indirect heat to the area - causes inflammation which can lead to obstructions
Hands, feet, joints, eyes self-care deficit Ears, nose, buttocks, perineum infection
There can be contamination from urine and feces: buttocks and perineum Ear and nose have a poor blood supply
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Classification of Burn InjuryLocation of Burn
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Eschar formation can cut off blood supply and interfere with healing Circumferential burn to the chest area: interfere with
breathing, constrict the chest wall to move make sure the pt is breathing and doesnt develop
Patients may also develop compartment syndrome
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Classification of Burn InjuryPatient Risk Factors
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Pre-existing cardiovascular, respiratory, and renal diseases contribute to poorer prognosis
Diabetes mellitus and peripheral vascular disease contribute to poor healing and gangrene will be more difficult to recover
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Classification of Burn InjuryPatient Risk Factors
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Physical debilitation renders patient less able to recover Alcoholism Drug abuse Malnutrition
Concurrent fractures, head injuries, or other trauma leads to a more difficult time recovering Difficult time to recover
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Resuscitation/Early Phase of Burn Injury
Continues for about 24 to 48 hours
The resuscitation phase is the first phase of a burn injury. It begins at the onset of injury and continues for about 24 to 48 hours. During this phase, the injury is evaluated and the immediate problems of fluid loss, edema, and reduced blood flow are assessed. The priorities for management during this period are to (1) secure the airway, (2) support circulation by fluid replacement, (3) keep the patient comfortable with analgesics, (4) prevent infection through careful wound care, (5) maintain body temperature, and (6) provide emotional support.
Vascular changes that occur: Fluid shifts from vascular to interstitial space capillary leak syndrome concerned with the systemic effects of the burn: ABCs are priority
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Goals of management?
General Management for All Types of Burns
Assess for airway patency.
Administer oxygen as needed.
Cover the patient with a blanket.
Keep the patient on NPO status.
Elevate the extremities if no fractures are obvious.
Obtain vital signs.
Initiate an IV line, and begin fluid replacement.
Administer tetanus toxoid for prophylaxis.
Perform a head-to-toe assessment.
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Goals of management?
Specific ManagementFlame Burns
Smother the flames.
Remove smoldering clothing and all metal objects.Chemical Burns
If dry chemicals are present on skin or clothing, DO NOT WET THEM.
Brush off any dry chemicals present on the skin or clothing.
Remove the patient's clothing.
Ascertain the type of chemical causing the burn.
Do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available.
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Goals of management?
Electrical Burns
At the scene, separate the patient from the electrical current.
Smother any flames that are present.
Initiate cardiopulmonary resuscitation.
Obtain an electrocardiogram (ECG).Radiation Burns
Remove the patient from the radiation source.
If the patient has been exposed to radiation from an unsealed source, remove his or her clothing (using tongs or lead protective gloves).
If the patient has radioactive particles on the skin, send him or her to the nearest designated radiation decontamination center.
Help the patient bathe or shower.
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Goals of management?
Concerned with the systemic effects of the burn ABC is a priority
Airway/respiratory first Assess for signs of inhalation injuries: facial involvement,
singed hair on face, mouth is black
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BreathingKey signs that your patient is deteriorating for inhalation injury
Hoarseness, brassy cough, difficulty swallowing, drooling, stridor wheezing Look at respiratory effort (use of accessory muscle) If patient shows signs of inhalation injury, what will you as the nurse do?
Interventions Give oxygen Call Rapid Response! prepare for intubation
Make sure there is intubation equipment at the bedside Once they are showing signs of inhalation injury, there are at risk for
respiratory arrest/failure, the airways getting more narrow Suction HOB elevated: Sit patient up, turning pt frequently Encourage patient to use incentive spirometer Monitor ABGs labs
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Factors Determining Airway Obstruction or Inhalation Injury
Patients who were injured in a closed space
Patients with extensive burns or with burns of the face
Intra-oral charcoal, especially on teeth and gums
Patients who were unconscious at the time of injury
Patients with singed scalp hair, nasal hairs, eyelids, or eyelashes
Patients who are coughing up carbonaceous sputum
Changes in voice such as hoarseness or brassy cough
Use of accessory muscles or stridor
Poor oxygenation or ventilation
Edema, erythema, and ulceration of airway mucosa
Wheezing, bronchospasm
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Factors Determining Airway Obstruction or Inhalation Injury
A change in respiratory pattern may indicate a pulmonary injury. The patient may:
Become progressively hoarse
Develop a brassy cough
Drool or have difficulty swallowing
Produce sounds on exhalation that include audible wheezes, crowing, and stridor
Any of these changes may mean the patient is about to lose his or her airway. Immediately apply oxygen and call Dr
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Circulation
C - Patient is at risk for hypovolemic shock: big cause of death in this phase Fluid resuscitation must be started immediately! Monitor edema, urine output, vital signs (BP, pulse) To determine how much fluid infusion the pt needs we use Parkland formula
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Fluid Resuscitation of the Burn Patient
Initiate and maintain at least one large-bore IV in an area of intact skin (if possible).
Coordinate with physicians to determine the appropriate fluid type and total volume to be infused during the first 24 hours postburn.
Administer one half of the total 24-hour prescribed volume within the first 8 hours postburn and the remaining volume over the next 16 hours.
Assess IV access site, infusion rate, and infused volume at least hourly.
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Fluid Resuscitation of the Burn Patient
Monitor these vital signs at least hourly:
Blood pressure
Pulse rate
Respiratory rate
Breath sounds
Voice quality (if not intubated)
Oxygen saturation
End-tidal carbon dioxide levels
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Fluid Resuscitation of the Burn Patient
Assess urine output at least hourly:
Volume
Specific gravity
Color
Character
Presence of protein
Assess for fluid overload:
Formation of dependent edema
Engorged neck veins
Rapid, thready pulse
Presence of lung crackles or wheezes on auscultation
Measure additional body fluid output hourly
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Application of Parkland Formula
A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient was found at home at 8am and arrived to the hospital at 10am. How much fluid should be administer in the first 8 hours? Calculate the
rate.
4 x patient weight in kg x TBSA : this will give you the total volume of fluid First 8 hours administer half of the total volume Must infuse within the first 8 hours: time starts from when the burn injury
occurred, not the time they arrived at the hospital. Rate divided by 6 instead of 8 EX. A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient
was found at home at 8am and arrived to the hospital at 10am.
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Application of Parkland Formula
How much fluid should be administer in the first 8 hours? Calculate the rate.
154 lbs= 70kg 4ml x 70kg x 50% = 14,000 14,000 : 2 = 7,000 ml 7,000ml : 6h = 1,167 ml/h
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Evaluation after Giving Fluids
Monitor their response: Urine output is a key indicator, Vital signs (BP, HR)
Patient will have a foley catheter to measure UOP accurately Facial Edema Before and After Fluid Resuscitation
Treat pain: Morphine, Dilaudid Monitor closely PCA pump
P - PainStrong pain meds: if pt will have a respiratory depression he
has to be intubated
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Facial Edema Before and After Fluid Resuscitation
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Escharotomy Fasciotomy
Surgical Management of Burns
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Escharotomy Fasciotomy
Surgical Management of Burns
Incision made through tight eschar to relieve pressure and allow normal blood flow and breathing.
A surgical procedure in which an incision is made through the skin and subcutaneous tissues into the fascia of the affected compartment to relieve the pressure in and restore circulation to the affected area in the patient with acute compartment syndrome.
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Escharotomy - eschar can cut off blood supply and interfere with healing, can be done at the bedside
Fasciotomy - under anesthesia
**Although a patient may come in with a horrific burn injury, were more worried about systemic effects that are acutally more detrimental
Surgical Management of Burns
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Acute Phase of Burn Injury
Begins about 36 to 48 hr after injury; lasts until wound closure is completed Fluid starts to shift back from interstitial into the
vascular space Urine output will increase even more
Goals of management? Concern about infection Wound care Nutrition Mobility
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Acute Phase of Burn Injury
Infection prevention Sterile technique No flowers in the room At risk for pseudomonas Minimize visitors: children and those with illness should not be allowed Immunization: Depends on pt immunization status, tetanus ( burn wound
is breeding ground for the organism) Only give systemic antibiotics and only if patient is showing signs of
infections Signs of infection: look at the wound, temperature Hyperinflammatory response: high temperature - give nsaids, tylenol,
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Acute Phase of Burn Injury
Wound care: Debriding: remove dead tissue, ensure viable tissue to
promote healing Risk for hypothermia - because skin is removed Premedicate with pain medication before wound care Once debrided, a topical ointment is applied Silvedine
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Acute Phase of Burn Injury
Nutrition Requires a lot of calories hypermetabolic state
burns more calories Can exceed 5,000 calories/day High protein, high protein supplements Can request food at any time, consider the patients
preferences Promotes healing
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Acute Phase of Burn Injury
Mobility:
Prevent contractures: ROM to the affected extremity
Scar formation can limit the range of motion ability
Out of bed as soon as possible
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Rehabilitative Phase of Burn Injury
Begins with wound closure, ends when patient returns to highest possible level of functioning
Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity
Social work, referrals
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Rehabilitative Phase of Burn Injury (contd)
This phase may last years or even a lifetime if patient needs to adjust to permanent limitations
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A patient arrives to the ED with superficial facial burns from an explosion in his apartment building. He has productive carbonaceous sputum with labored respirations and singed hair.Based on these findings what is the highest priority of care for this patient?
Airway! Patient is showing signs of inhalation injury: carbonaceous sputum,
singed hair, labored respirations
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Which symptoms may indicate a pulmonary injury from the inhalation? (Select all that apply.)
A. Development of a brassy coughB. DroolingC. Clear speechD. Audible wheezeE. Clear breath sounds
(contd)
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Twenty minutes later, assessment of the patient reveals loud wheezing on exhalation. What is the nurses best action at this time?
A. Check the patients SaO2 with pulse oximetry.B. Apply oxygen and call the Rapid Response Team.C. Call a CODE and bring the crash cart to the room.D. Call respiratory therapy for a treatment with a bronchodilator.
(contd)
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AUDIENCE RESPONSE SYSTEM QUESTIONS
Chapter 28
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Question 1
A patient is admitted to the ED with burns to his lower legs and hands after a gas can exploded. What is the initial nursing priority on admission?
A. Assess and treat his pain. step 4B. Use the rule of nines to estimate his percent of body surface area
burned. step 2C. Evaluate his airway and circulation. step 1D. Place two IV catheters and initiate fluid resuscitation. step 3
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Question 2
It has been 12 hours since a patient has been admitted for burns to his face and neck and for inhalation injuries. He had been wheezing audibly, but at this time the nurse notes that his wheezing has stopped. What should the nurse do?
Document this improvement in the patients condition. Re-assess his breathing in an hour.Check the patients SPO2 level.Notify the physician immediately.
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Question 3
A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patients white blood cell count has dropped significantly over the past 4 days. What may this change indicate?
A. The patients infection is improving.B. The patient is having an allergic reaction to the silver sulfadiazine.C. The patient has kidney disease.D. The patient has an electrolyte imbalance.