burns burn injury and the number of deaths - dropped in the past 10 years -decrease is from: -use of...

BURNS Burn injury and the number of deaths - dropped in the past 10 years -decrease is from: -use of smoke detectors -creation of regional burn centers -national focus on safety -occupational safety mandates

Causes -Thermal or nonthermal causes. -Thermal burns -most common type of burn injury -caused from heat -flames, scalds, thermal energy -Nonthermal burns -electricity, chemicals, and radiation.

Causes Skin destruction -depends on the burning agent -condition of the skin before injury -duration of the persons contact with the agent

Severity of burns The factors that determine the severity of a burn are: -Percentage of the body surface area burned. - Age -Specific location of the burn. -Cause -Other diseases -Depth of the burn. -Injuries

THERMAL BURNS

NONTHERMAL BURNS

Depth of burns/Classification Superficial thickness injuries Partial-thickness injuries Full-thickness injuries - graphically describe the burn -depth and severity of the tissue injury See AHN p. 95, Table 3-3 for descriptions of the burn classifications. -If you use only the visual characteristics of the burn wound, it would not provide an accurate assessment of how much damage might have been caused.

First Degree Burns

Second Degree Burns

Third Degree Burns

Percentage Estimates The RULE OF NINES - determines the total body surface area (BSA) burned. See p. 106, FIGURE 3-22. The rule of nines divides the body into multiples of nine. -Head to neck 18% -Arm (shoulder to fingertips) 9% each -Anterior trunk 18% -Posterior trunk 18% -Leg (groin to toe) 14% each

Age considerations Percentage of body area burned in infants and children -the surface area of the childs head is larger Increased risk to develop circulatory -adults with cardiac disease -the very old -the very young overload.

Burns Dramatic changes -first few minutes to the first 12-24 hours

Extent of the burns? -greater the 20% -cause massive evaporative of water -fluid losses into the interstitial space -capillaries dilate (hypermeablitiy) for 24 hours -fluid shifts from the capillaries to the interstitial spaces -causes edema and blistering (third spacing) -cells become dehydrated -hypovolemic shock starts - hypotension and decreased renal flow

Three stages of medical treatment 1. Emergent Phase (Stage 1) Decreased volume and shock -occur up to 48 hours after being burned.

Three stages of medical treatment 2. Acute Phase (Stage 2) -48-72 hours after a burn -circulatory overload - secondary to fluid shifting back from the interstitial spaces to the capillaries - increased urine output -diuretic stage

3. Rehabilitation Phase (Stage 3) -wound treatment begins -slowly returns to as normal status as possible

Complications Carbon Monoxide (CO) poisoning -Person in an enclosed area during a fire -CO displaces O2 from hemoglobin -Dont rely on oximeters - cant distinguish from oxyhemoglobin and carboxyhemoglobin -Early signs- -headache -nausea -vomiting - unsteady gait -Treatment- 100% oxygen

Smoke Inhalation Inhaling chemicals produced by the fire Damages- -celia and mucous membranes of the respiratory tract Symptoms- -several hours after the initial burn High risk for patients -upper chest, neck and face burns

Smoke Inhalation -hoarse voice -gutteral breath sounds -productive cough -redness/swelling -sooty sputum -nasal or oral pharynx -singed nasal hairs -agitation -tachypnea -flaring nostrils -intercostal retractions - grunting

Smoke Inhalation Treatment -establish airway -initiate oxygen -may need intubation

Shock Emergent phase -fluid shifting from the capillaries to the interstitial spaces. Requires fluid resuscitation (IV fluids) -Adults-greater then 20% of their body surface -Children-10 % -Older then 55 -Younger then 14 years -Cardiac, pulmonary disease or diabetic -Electric burns

IV fluid therapy -central line of Lactate Ringers -amount of fluid given -body weight -percentage of body surface burned. Foley catheter -monitors urine output. -30-50 cc/hour urine output -maintain adequate renal function Airway -continue to maintain -vital signs monitored

Infection Most common cause of death in the first 72 hours in burn victims Nursing implications -erythema, odor, green or yellow exudate -wound culture and sensitivity -topical bacteriostatics -capillaries are coagulated by the burns

Protective Isolation -gown, mask, cap and glove -dressing changes require strict surgical aseptic techniques.

Immediate Medical Management 1. Establish an airway -Oxygen -intubated to ensure a patent airway 2. Initiate fluid therapy -Insert a central IV line -Ringers Lactate IV immediately -the amount depends on: -body weight and the -percentage of the body surface area burned

3. Renal function and urine output -insert a foley catheter -maintain a 30-50cc/hour urine output to perfuse the kidneys -adjust the IV fluid to maintain adequate urine output 4. Pain control -Morphine IV -small doses given frequently

-3-5mg IV every 5-10 minutes until pain relived -Children- 0.1-0.2 mg/kg every 2-4 hours PRN -Hypovolemic -effects of analgesic may increase -Monitor for respiratory depression -Fentanyl may be an alternative if the client is allergic to Morphine

6. Body temperature -chilling -secondary to the skin being left open to the air for wound healing. -keep room at 85 degrees and humidity at 40-50% -light and heat lamps (use caution) 7. Infection control -Tetanus immunization if client is not up to date, -Wound infections-topical bacteriostatics -Systematic infections (pneumonia) -IV antibiotics.

Recovery Phase - 10 days to several months depending on severity of the burns -72 hours after a burn injury -increased metabolism -decreased urine output -decreased edema -Goals -treat burn wounds -prevent and manage complications

Prevent Complications -Infections -heart failure -renal failure -extremity contractures -paralytic ileus -Curlings ulcer

Wound Debridement Debridement -removes the damaged tissue/debris from a wound or burned tissue -prevents infection -promotes healing Partial thickness wounds -debrided twice a day -topical antibiotic -dressing applied

Eschar removal Black leathery crust -forms over burned tissue -holds in micro-organisms -causes infection Escharectomy- -cutting down to the healthy tissue -chest expansion is restricted -burns around the chest, arms or legs

Debridement -Helps with regeneration of the tissues -Enzymes -applied topically -chemically debride the eschar -Hydrotherapy -softens the eschar with water -makes debridement less painful -promotes range of motion the extremities - preventing contractures

Debridement Failure to debride -increased the chance for infection -delays healing -increases scarring

WOUND CARE -Severity of the burn -Open (exposure) method -burns of the face, neck, ears, and perineum -cleaned and exposed to air -hard crust forms -regeneration of tissue occurs -advantages : -wound can be observed -body part is not restricted -circulation is not compromised -exercises can be performed more easily

Pain Control Changing the dressing will be PAINFUL!!!!! -Analgesics-given at least 30 minutes before dressing changes -IV Morphine -Remove dressings after hydrotherapy

Rehabilitation -Less the 20% BSA remains burned -Physical and Occupational Therapy work -improve endurance, strengthening and independence in ADLs Nursing Implications -realistic short term goals-keep the client motivated -encourage to verbalize feelings about his changed body image

Surgical Options Skin Grafts- -Prevents the scar tissue -disfigurement -and loss of mobility -Required for burns -disrupted the epidermis -most of the dermis

Surgical Options -Promotes healing -Prevents infection -First 3 weeks after a burn -4 types of grafts -auto graft -homograft -heterograft -synthetic graft

Auto graft Surgical transplantation of tissue from one part of the body from the same person

Homograft Surgical transfer of tissue from two genetically different individuals of the same species -a temporary graft can be from a cadaver

Heterograft Tissue from another species -Temporary graft

Synthetic Graft Made from a variety of materials such as neonatal human fibroblast cells TransCyte developed in 1997 -applied only once -temporary covering -protect against fluid loss -decreases the chance of infection

Methods of application of grafts Pedicule method -partially attached to the donor site and the other portion is attached to the burn site Free standing method -tissue is completely removed from the donor site and attached to the burn site

Client education 1. Do not to remove the dressing until the physician orders the removal. 2. Report bruising or fluid collection under the graft to the physician. 3. Protect the skin graft from sunlight/use sunscreen to the graft site for 6 months after the surgery. 4. Use lotion to the skin graft site for 6-12 months. 5. Wear elastic stocking when having skin grafts to the lower extremities for 4-6 months

Pharmacology Anti-Infectives, Antiseptics and Germicides- -Topical medications -prevent wound infections Types- Sulfamylon Silvadene Silver Nitrate Furacin Gentamycin Neomycin

Pharmacology Antibiotics- -Cultured wound infections -Periods before and after surgical procedures -Maintains a therapeutic blood level -gives equal doses -evenly spaced over 24 hours.

Narcotics -narcotic analgesics given for pain control -Morphine -Fentanyl can be substituted if the client has a allergy Topical Agents- -Scarlet Red- -drying agent applied to dressings on donor sites -no antiseptic effects -stains and irritates the skin -monitor infection under the dyed gauze

Xerophorm- -promotes epitheliazation -debrides -protects donor and graft sites -can adhere to the site -not antiseptic Dakins Solution- -chlorine bactericidal solution -debrides the wound -cleans large amounts of drainage -inhibit clotting/dissolves blood clots -can irritate the skin

Travase- -topical enzyme -dissolves necrotic tissue -removes eschar/purulent drainage -mild pain on application -numbness, bleeding and dermatitis -dressings must be kept moist at all times

NUTRITIONAL NEEDS OF THE BURN PT. -should eat by mouth as soon as possible -intake needs must meet the demands of the healing body -increased requirements for protein and calories. -Normal protein needs are 0.8 g per kg. of body weight -Burned pt. needs 1.5-3.2 g per kg. of body weight per day

NUTRITION -Calories -2000-6000 per day -foods need to be concentrated -high in calories -more vitamins- A,B, and C -promote digestion, absorption, and repair of tissue -Vitamin B complex helps in the metabolism of the extra proteins and carbohydrates. -increased amounts of calcium, zinc, magnesium, iron.

-Most burn victims have poor appetites -frequent, small feedings are offered. -Curlings ulcer 8-14 days after the burn injury. - Prophylactic treatment -Tagamet (IV/oral), Zantac, or Prilosec.

Enteral Feedings - Nasal gastric (N/G) tube -burn client is unable to eat -secondary to facial or throat burns -unable to take in adequate calories to meet his needs. -Low rate continuous solution ( 2 Cal, Jevity, etc.) -administered over 24 hours/day via pump. -2-3L of solution -weighed daily -urine output is measured -BUN, creatine, glucose and electrolytes - drawn and monitored daily.

Lower incidence of abnormalities, sepsis and mortality -enteral feedings started in the first 24 hours after the client is hospitalized

Total Parental Nutrition (TPN) IV nutrition -usually administer along with enteral nutrition -administered alone -disturbances with GI motility -N/G intolerance -inability to absorb enough calories or protein

Total Parental Nutrition (TPN) IV solution -composed of concentrated glucose, electrolytes, amino acids, insulin, vitamins, trace minerals. -lipid solution -piggybacked with the solution. -central IV line (PICC, PAC, Groshong)

Monitor CBG every 6 hours Signs of fluid overload or infection Daily labs- -electrolytes -liver function tests -BUN/Creatine -albumin levels -weekly

ASSESSMENT SUBJECTIVE DATA: -causative agent -other diseases present -temperature of the fire -duration of contact -patients age. -level of pain -scale of 0-10.

ASSESSMENT OBJECTIVE DATA: -depth of the burn -skin thickness involved -percentage of body surface (BSA) area burned -other injuries sustained -specific location of burns -Other disease processes that have an effect on the outcome of the burn.

ASSESSMENT -Burn that involves the face, neck, or chest -observe him for any respiratory complications. -If the pt. has had a tetanus booster in the past 5 years. -The severity of the burn depends on several factors.

NURSING DIAGNOSES -Emergent phase of burns Ineffective airway clearance, related to edema of the respiratory passages Deficient fluid volume (dehydration), related to shift of body fluids Deficient fluid volume, related to capillary hyper permeability with fluid moving out of the cells into the interstitial area Acute anxiety, related to injury Acute pain, related to loss of skin

NURSING DIAGNOSES Risk for infection, related to impairment of skin integrity Impaired skin integrity, related to damage by the burns Decreased cardiac output, related to hypovolemia Risk for aspiration, related to decreased peristalsis Impaired swallowing, related to mucosal edema

NURSING DIAGNOSES Impaired verbal communication, related to breathing difficulties Disturbed sleep pattern, related to hospital environment

Nursing Diagnosis -Acute phase -Acute anxiety, related to change in body image -Fear, related to chronic illness -Chronic pain, related to procedures performed -Risk for infection, related to open skin wounds -Imbalanced nutrition, less than body requirements, related to increased metabolic demands -Social isolation, related to perceived change in body image -Impaired physical mobility, related to burns

NURSING DIAGNOSES Self-care deficit, in activities of daily living, related to area of burn involved Deficient knowledge, all areas, related to expected care Interrupted family processes, related to long-term hospitalization Disturbed body image, related to disfigurement from burns

NURSING DIAGNOSES Deficient diversional activity, related to confinement during care Ineffective coping, related to seriousness of injury and perceived role changes Powerlessness, related to prolonged recovery, loss of income, loss of physical attractiveness

NURSING DIAGNOSES - Rehabilitation Phase Ineffective airway clearance, related to edema of the respiratory passages Impaired physical mobility, related to splinting, dressings, or pain Activity intolerance, related to prolonged bed rest Anxiety, acute to moderate, related to role change Disturbed body image, related to scarring

NURSING DIAGNOSES Deficient knowledge, related to impaired home maintenance management Self-care deficit, related to pain or fatigue Fear, related to impending surgery Risk for disuse syndrome, related to noncompliance Post-trauma syndrome, related to the cause of the burn

NURSING DIAGNOSES Impaired adjustment, related to lack of ability to limited expectations of self Ineffective coping. Related to long-term rehabilitation Disturbed personal identity, related to inability to return to previous lifestyle for prolonged period Care-giver role strain, related to prolonged recovery period

NURSING DIAGNOSES Ineffective management of therapeutic regimen, related to complexity and chronicity of rehabilitation Anticipatory grieving, related to loss of wellness

HOME HEALTH TEACHING -Bathe twice a day with a mild soap -Avoid extremes of water temperature -Only enter a very clean tub or shower. -Take a lukewarm bath - Alpha Keri lotion relieves itching. -Avoid lotions with alcohol or lanolin -they cause blisters

TEACHING -Avoid direct sunlight. -Scarring is part of the healing process -Scars are red - then become softer and lose their color. -Report these signs to the PCP: -fever (temp. >101 degrees F) -s/s of infection -feeling of inability to cope.

PROGNOSIS -Depends on many factors: - size and depth of the burn -body part that was burned -burning agent -other pre-existing diseases/conditions. -Burn care is very extensive -Many times the patient must change his vocation, his job. It affects relationships, social situations, self-esteem, etc.

Questions??

burns burn injury and the number of deaths - dropped in the past 10 years -decrease is from: -use of...

Documents

nonthermal burns slide

agent slide

oxygen slide

possible slide

renal flow slide

burn depth

burn wound

burn classifications